Pennsylvania requires a medical evaluation for every assisted living resident. A physician, physician's assistant, or certified registered nurse practitioner must perform it. This requirement comes from 55 Pa. Code Section 2800.141. The evaluation must cover a general physical exam, diagnoses, allergies, immunizations, and mobility. It must also list medications, including any that are contraindicated or carry side effects.
Tuberculosis screening is part of the same evaluation. Residents need a negative TB skin test from within the prior two years. A positive test result requires a chest X-ray instead. The facility must complete this testing within 15 days after admission.
The evaluation is not a one-time record. Facilities must update it at least annually, and sooner if a resident's medical condition changes. The Department can review these forms to confirm each resident's service plan still matches their current needs.
Medical evaluation by a physician
One of the most important elements of admitting a new resident is 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 DHS has regulated this process, check it out below:
- 2800.141. Resident medical evaluation and health care.
(a) A resident shall have a medical evaluation by a physician, physician’s assistant or certified registered nurse practitioner documented on a form specified by the Department, subject to the provisions of § 2800.22 (relating to application and admission). The evaluation must include the following:
(1) A general physical examination by a physician, physician’s assistant or nurse practitioner.
(2) Medical diagnosis including physical or mental disabilities of the resident, if any.
(3) Medical information pertinent to diagnosis and treatment in case of an emergency.
(4) Special health or dietary needs of the resident.
(5) Allergies.
(6) Immunization history.
(7) Medication regimen, contraindicated medications, medication side effects and the ability to self-administer medications.
(8) Body positioning and movement stimulation for residents, if appropriate.
(9) Health status.
(10) Mobility assessment, updated annually or at the Department’s request.
(11) An indication that a tuberculin skin test has been administered with negative results within 2 years; or if the tuberculin skin test is positive, the result of a chest X-ray. In the event a tuberculin skin test has not been administered, the test shall be administered within 15 days after admission.
(12) Information about a resident’s day-to-day assisted living service needs.
(b) A resident shall have a medical evaluation:
(1) At least annually.
(2) If the medical condition of the resident changes prior to the annual medical evaluation.
Top Takeaway:
- (b) A resident shall have a medical evaluation:
(1) At least annually.
(2) If the medical condition of the resident changes prior to the annual medical evaluation.
The medical evaluation form needs to be updated on an annual basis as well as after any change in medical condition for the resident. The DHS will be examining these documents to ensure the residents in your community have an up-to-date service plan.