One of the most important elements of admitting a new resident in the initial physical examination by a physician. This process will determine if you are able to provide the services that this resident will require, ultimately deciding if you can move forward with admitting this resident. Unfortunately, your facility is not equipped to handle every person who walks through its doors and it is better to know this at the beginning rather than 3 weeks after the resident moves into your community. In order to ensure communities are providing due diligence before admitting residents, the OHFLAC has regulated this process, check it out below:
6.3. Assessments and Service Plans.
6.3.1. Each resident shall have a written, signed, and dated health assessment by a physician or other licensed healthcare professional, authorized under state law to perform this assessment, not more than 60 days prior to the resident’s admission, or no more than five working days following admission, and at least annually after that. The admission and annual health assessment shall include screening for tuberculosis and other communicable diseases if indicated by exposure, prevalence, or risk according to current medical practice to congregate living situations as indicated by the Secretary. The licensee shall maintain documentation of the assessment in the resident’s medical record. (Class II)
6.3.2. Within five days of admission, each resident shall have an individualized functional needs assessment completed in writing by a licensed health care professional which is maintained in the resident’s medical record. At a minimum, the resident’s assessment shall include a review of health status and functional, psycho-social, activity, and dietary needs. (Class II)
6.3.3. Within seven days of admission, each resident shall have a service plan based upon his or her functional needs assessment and individual needs that includes, but is not limited to, the type of assistance needed to perform activities of daily living; the ability to receive prescribed medications and treatments; the ability to follow any planned diet, rest, or activity regimen; the ability to engage in activities and programs appropriate to the individual’s level of functioning; and the ability to use equipment such as hearing aids, glasses, and canes. Staff shall have access to the service plan, use it as a guide for providing resident care, and maintain it as a part of the resident’s medical record. (Class II)
6.3.4. The licensee shall ensure that the functional needs assessment and service plans reflect the resident’s current needs and are updated annually or as indicated by a significant change in the resident’s condition. (Class II)
Top Takeaways:
- 3.1. Each resident shall have a written, signed, and dated health assessment by a physician or other licensed health care professional, authorized under state law to perform this assessment, not more than 60 days prior to the resident’s admission, or no more than five working days following admission, and at least annually after that. The admission and annual health assessment shall include screening for tuberculosis and other communicable diseases if indicated by exposure, prevalence, or risk according to current medical practice to congregate living situations as indicated by the Secretary. The licensee shall maintain documentation of the assessment in the resident’s medical record. (Class II)
The preadmission physician assessment is an area where state surveyors often focus. They will pick assessments at random and review them for accuracy and compliance. Many facilities are tagged because of the negligence towards thoroughly auditing these documents.
- 3.3. Within seven days of admission, each resident shall have a service plan based upon his or her functional needs assessment and individual needs that includes, but is not limited to, the type of assistance needed to perform activities of daily living; the ability to receive prescribed medications and treatments; the ability to follow any planned diet, rest, or activity regimen; the ability to engage in activities and programs appropriate to the individual’s level of functioning; and the ability to use equipment such as hearing aids, glasses, and canes. Staff shall have access to the service plan, use it as a guide for providing resident care, and maintain it as a part of the resident’s medical record. (Class II)
The service plan essentially builds the task list of what services your care team will be providing to the resident. The service pan must be accurate and up to date to reflect the current needs of each resident.