Utah Administrative Code
Topic - Health
Title R432 - Health Care Facility Licensing
Rule R432-151 - Mental Disease Facility
Section R432-151-13 - Resident Care Plans
Universal Citation: UT Admin Code R 432-151-13
Current through Bulletin 2024-06, March 15, 2024
(1) These rules shall apply in addition to R432-150-13 and shall provide emphasis regarding resident care plans.
(2) The written resident care plan shall be based on a complete assessment of each resident, and should include the resident's physical, emotional, behavioral, social, recreational, legal, vocational, and nutritional needs.
(a) The
facility staff shall obtain, review, and update assessment data.
(b) When information has been obtained by
other facilities or agencies prior to the resident's admission, reports should
be obtained which cover the required assessments.
(3) The preliminary resident care plan shall be completed within seven days of admission.
(a) Plans must be reviewed on a monthly basis
for the first three months; thereafter at intervals determined by the
interdisciplinary team but not to exceed every other month at approximately
60-day intervals.
(b) When a
resident is discharged and readmitted, a new resident care plan must be
developed.
(4) A physician or nurse practitioner shall assess each resident's physical health within five days prior to or within 48 hours after admission.
(a) A history and physical exam shall be done
which includes appropriate laboratory work-up;
(b) a determination of the type and extent of
special examinations, tests, or evaluations needed; and
(c) when indicated, a thorough neurological
exam.
(5) A written comprehensive health assessment, compiled by professional staff members, shall include the following:
(a) Alcohol and drug
history including the following:
(i) drugs
used in the past;
(ii) drugs used
recently, especially within the preceding 48 hours;
(iii) drugs of preference;
(iv) frequency with which each drug is
used;
(v) route of administration
of each drug;
(vi) drugs used in
combination;
(vii) dosages
used;
(viii) year of first use of
each drug;
(ix) previous
occurrences of overdose, withdrawal, or adverse drug reactions;
(x) history of previous treatment received
for alcohol or drug abuse;
(b) Degree of physical disability and
indicated remedial or restorative measures including:
(i) nutrition,
(ii) nursing,
(iii) physical medicine, and
(iv) pharmacologic intervention;
(c) Degree of psychological
impairment and appropriate measures to be taken to relieve treatable distress
or to compensate for non-reversible impairments;
(d) Capacity for social interaction and what
appropriate rehabilitation or habilitation measures are to be undertaken,
including group living experiences and other activities to maintain or increase
the individual's capacity to independently manage daily living.
(e) A written emotional or behavioral
assessment of each resident shall be entered in the resident's record. The
assessment shall include the following:
(i) A
history of previous emotional or behavioral problems and treatment;
(ii) The resident's current level of
emotional and behavioral functioning;
(iii) A psychiatrist's evaluation within 30
days prior to or within one week after admission;
(iv) When indicated, a mental status
assessment appropriate to the age of the resident;
(v) When indicated, psychological assessments
which include intellectual and personality testing;
(vi) Other functional assessments such as
language, self-care ability, and visual-motor coordination.
(f) A written social assessment of
each resident shall include information about the following:
(i) Home environment;
(ii) Childhood history;
(iii) The resident's family circumstances;
the current living situation; social, ethnic, and cultural background; sexual
abuse;
(iv) Resident and family
strengths and weaknesses;
(v)
Military service history if applicable;
(vi) Financial resources;
(vii) Religion;
(g) A written activities assessment of each
resident shall include information about current skills, talents, aptitudes,
interests, and attitudes.
(h) A
nutritional needs assessment shall be conducted and documented.
(i) When appropriate, a written vocational
assessment of the resident shall include:
(i)
Previous occupations including brief descriptions of the type of work, duration
of employment, reasons for leaving, etc.;
(ii) Education history, including academic or
vocational training;
(iii) Past
experiences and attitudes toward work, present motivations, areas of interest,
and possibilities for future education, training, or employment.
(j) When appropriate, a written
assessment of the resident's legal status shall include:
(i) A history with information about
competency, court commitment, prior criminal convictions, any pending legal
actions;
(ii) The urgency of the
legal situation;
(iii) How the
individual's legal situation may influence treatment.
(k) The facility shall develop procedures
which describe early intervention for symptoms that are life-threatening, are
indicative of disorganization or deterioration, or may seriously affect the
treatment process.
(l) The resident
care plan shall comply with
R432-150-13(4)
and include the following:
(i) Treatment
goals expressed as standards of achievement;
(ii) Services or treatment to be provided
(based on assessments), at what intervals, and by whom;
(iii) Nutritional requirements;
(iv) Security precautions;
(v) Precautions and interventions for
maladaptive behaviors;
(vi)
Restrictions or loss of privileges, if any; factors to regain
privileges;
(vii) Date the plan was
initiated and dates of subsequent reviews;
(viii) Discharge planning.
Disclaimer: These regulations may not be the most recent version. Utah may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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