Conducting the resident assessment | WI

Conducting the resident assessment

One of the most important elements of admitting a new resident is the initial physical examination by a physician along with the assessment your clinical team preforms. 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. To ensure communities are providing due diligence before admitting residents the WDHFS has regulated this process, check it out below:

DHS 83.35 Assessment, individual service plan and evaluations.

(1)  Assessment.

(a) Scope. The CBRF shall assess each resident’s needs, abilities, and physical and mental condition before admitting the person to the CBRF, when there is a change in needs, abilities or condition, and at least annually. The assessment shall include all areas listed under par. (c). This requirement includes individuals receiving respite care in the CBRF. For emergency admissions the CBRF shall conduct the assessment within 5 days after admission.

(b) Information gathering. The CBRF shall base the assessment on the current diagnostic, medical and social history obtained from the person’s health care providers, case manager and other service providers. Other service providers may include a psychiatrist, psychologist, licensed therapist, counselor, occupational therapist, physical therapist, pharmacist or registered nurse. The administrator or designee shall hold a face-to-face interview with the person and the person’s legal representative, if any, and family members, as appropriate, to determine what the person views as his or her needs, abilities, interests, and expectations.

(c) Areas of assessment. The assessment, at a minimum, shall include all of the following areas applicable to the resident:

1. Physical health, including identification of chronic, short-term and recurring illnesses, oral health, physical disabilities, mobility status and the need for any restorative or rehabilitative care.
2. Medications the resident takes and the resident’s ability to control and self-administer medications.
3. Presence and intensity of pain.
4. Nursing procedures the resident needs and the number of hours per week of nursing care the resident needs.
5. Mental and emotional health, including the resident’s self-concept, motivation and attitudes, symptoms of mental illness and participation in treatment and programming.
6. Behavior patterns that are or may be harmful to the resident or other persons, including destruction of property.
7. Risks, including, choking, falling, and elopement.
8. Capacity for self-care, including the need for any personal care services, adaptive equipment or training.
9. Capacity for self-direction, including the ability to make decisions, to act independently and to make wants or needs known.
10. Social participation, including interpersonal relationships, communication skills, leisure time activities, family and community contacts and vocational needs.

(d) Assessment documentation. The CBRF shall prepare a written report of the results of the assessment and shall retain the assessment in the resident’s record.

(2) Temporary service plan. Upon admission, the CBRF shall prepare and implement a written temporary service plan to meet the immediate needs of the resident, including persons admitted for respite care, until the individual service plan under sub. (3) is developed and implemented.

(3) Comprehensive individual service plan.

(a) Scope. Within 30 days after admission and based on the assessment under sub. (1), the CBRF shall develop a comprehensive individual service plan for each resident. The individual service plan shall include all of the following:

1. Identify the resident’s needs and desired outcomes.
2. Identify the program services, frequency and approaches under s. DHS 83.38 (1)the CBRF will provide.
3. Establish measurable goals with specific time limits for attainment.
4. Specify methods for delivering needed care and who is responsible for delivering the care.

(b) Development. The CBRF shall involve the resident and the resident’s legal representative, as appropriate, in developing the individual service plan and the resident or the resident’s legal representative shall sign the plan acknowledging their involvement in, understanding of and agreement with the plan. If a resident has a medical prognosis of terminal illness, a hospice program or home health care agency, as identified in s. DHS 83.38 (2) shall, in cooperation with the CBRF, coordinate the development of the individual service plan and its approval under s. DHS 83.38 (2) (b). The resident’s case manager, if any, and any health care providers, shall be invited to participate in the development of the service plan.

(c) Implementation. The CBRF shall implement and follow the individual service plan as written.

(d) Individual service plan review. Annually or when there is a change in a resident’s needs, abilities or physical or mental condition, the individual service plan shall be reviewed and revised based on the assessment under sub. (1). All reviews of the individual service plan shall include input from the resident or legal representative, case manager, resident care staff, and other service providers as appropriate. The resident or resident’s legal representative shall sign the individual service plan, acknowledging their involvement in, understanding of and agreement with the individual service plan.

(e) Documentation of review. The CBRF shall document any changes made as a result of the comprehensive individual service plan review.

(f) Availability. All employees who provide resident care and services shall have continual access to the resident’s assessment and individual service plan.

(4) Satisfaction evaluation. At least annually, the CBRF shall provide the resident and the resident’s legal representative the opportunity to complete an evaluation of the resident’s level of satisfaction with the CBRF’s services. The evaluation shall be completed on either a department form or a form developed by the CBRF and approved by the department.

Note: The CBRF Resident Satisfaction Evaluation form, F62372, can be found at http://dhs.wisconsin.gov/forms/DQAnum.asp or by contacting the Division of Quality Assurance Regional Office listed in Appendix A.

(5) Evaluation of resident evacuation limitations.

(a) Initial evaluation. The CBRF shall evaluate each resident within 3 days of the resident’s admission to determine whether the resident is able to evacuate the CBRF within 2 minutes in an unsprinklered CBRF and 4 minutes in a sprinklered CBRF without any help or verbal or physical prompting, and what type of limitations that resident may have that prevent the resident from evacuating the CBRF within the applicable period of time. A form provided by the department shall be used for the evaluation. The resident’s evaluation shall be retained in the resident’s record.

Note: The Resident Evacuation Assessment form, F62373, can be found at http://dhs.wisconsin.gov/forms/DQAnum.asp or by contacting the Division of Quality Assurance Regional Office listed in Appendix A.

(b) Evaluation update. The CBRF shall evaluate each resident’s mental or physical capability to respond to a fire alarm at least annually or when there is a change in the resident’s mental or physical capability to respond to a fire alarm.

(c) Notice to employees. The CBRF shall notify each employee who works on the premises of the CBRF of each resident who needs more than 2 minutes to evacuate the CBRF and the type of assistance the resident needs to be evacuated.

Top Takeaways:

• (1)
• The CBRF shall assess each resident’s needs, abilities, and physical and mental condition before admitting the person to the CBRF, when there is a change in needs, abilities or condition, and at least annually. The assessment shall include all areas listed under par. (c). This requirement includes individuals receiving respite care in the CBRF. For emergency admissions the CBRF shall conduct the assessment within 5 days after admission

The pre-admission assessment is a comprehensive assessment meant to discover the needs of a resident by performing a series of questions related to the residents functional/cognitive ability and their capability to evacuate the facility. This assessment is used to build the residents service plan of scheduled assistance. Once the assessment is conducted the results should be relayed to the individual and stored in their resident file.

• (d)Individual service plan review. Annually or when there is a change in a resident’s needs, abilities or physical or mental condition, the individual service plan shall be reviewed and revised based on the assessment under sub. (1). All reviews of the individual service plan shall include input from the resident or legal representative, case manager, resident care staff, and other service providers as appropriate. The resident or resident’s legal representative shall sign the individual service plan, acknowledging their involvement in, understanding of and agreement with the individual service plan.

The main point here is to ensure you are updating the service plan based upon any change in condition the resident has. You can guarantee the licensing survey team will review service plans to verify the services you are providing align with what us listed on the plan.

Pro Tip:

• Create an environment where all staff members ‘buy-in’ to the constant revision of service plans by communicating the ever-changing needs of the resident. So many people come in contact with a resident throughout the day and notice new needs or a change in condition but think nothing of communicating that to the care team.