Assessing the needs of your residents

Assessing the needs of your residents

As people age, they undoubtedly need more help with activities of daily living due to new clinical issues that arise. The same is true for your residents. When a resident moves into your community it is typically with the understanding that they will spend their remaining years living there, so understanding a resident’s needs prior to admission, upon admission as well the ongoing review of their care is vital to the resident’s health and wellness. Thankfully the DHSR has given ACHs guidelines as to how we can maintain the clinical care of residents as they age by conducting frequent assessments. Be sure to follow the following regulation to avoid being cited for a deficiency:

  • 131D-2.15.  Resident assessments.

(a)        Initial Assessment. – The Department shall ensure that facilities conduct and complete an assessment of each resident within 72 hours of admitting the resident. In conducting the assessment, the facility shall use an assessment instrument approved in accordance with rules adopted by the Medical Care Commission. The Department shall provide ongoing training for facility personnel in the use of the approved assessment instrument.

(a1)      Assessment to Develop Service Plans and Care Plans. – Within 30 days of admission, the facility shall conduct an assessment to develop appropriate and comprehensive service plans and care plans and to determine the level and type of facility staff that is needed to meet the needs of residents. The assessment shall determine a resident’s level of functioning and shall include, but not be limited to, cognitive status and physical functioning in activities of daily living. Activities of daily living are personal functions essential for the health and well-being of the resident. The assessment shall not serve as the basis for medical care. The assessment shall indicate if the resident requires referral to the resident’s physician or other appropriate licensed health care professional or community resource.

(a2)      Medicaid State Plan Personal Care Services Assessment. – To fulfill the activities of daily living portion of any service plan or care plan required under subsection (a1) of this section, or any rules adopted under this Article, the facility may use a service plan that was completed within 35 days of the resident’s admission to the facility and represents the result of an assessment to determine the resident’s eligibility for personal care services under the Medicaid State Plan. If the facility uses a service plan for personal care services under the Medicaid State Plan developed within 35 days of resident admission, the facility shall be exempt from conducting an assessment of the resident’s ability to perform activities of daily living within 30 days of resident admission. For purposes of this subsection, a resident must have received an assessment to develop appropriate and comprehensive service plans and care plans no later than 35 days after resident admission or subsection (a1) of this section applies.

(b)        Review. – The Department, as part of its inspection and licensing of adult care homes, shall review assessments and related service plans and care plans for a selected number of residents. In conducting this review, the Department shall determine all of the following:

(1)        Whether the appropriate assessment instrument was administered and interpreted correctly.

(2)        Whether the facility is capable of providing the necessary services.

(3)        Whether the service plan or care plan conforms to the results of an appropriately administered and interpreted assessment.

(4)        Whether the service plans or care plans are being implemented fully and in accordance with an appropriately administered and interpreted assessment.

(c)        Penalties. – If the Department finds that the facility is not carrying out its assessment responsibilities in accordance with this section, the Department shall notify the facility and require the facility to implement a corrective action plan. The Department shall also notify the resident of the results of its review of the assessment, service plans, and care plans developed for the resident. In addition to administrative penalties, the Secretary may suspend the admission of any new residents to the facility. The suspension shall be for the period determined by the Secretary and shall remain in effect until the Secretary is satisfied that conditions or circumstances merit removing the suspension.  (2009-462, s. 1(e); 2019-180, s. 1.)

Pro Tip:

  • Operating a compliant and efficient community boils down to having processes in line for EVERYTHING. Ensuring you have a process for the timely execution of resident assessments is key to providing the right care at the right time as well as staying in compliance with DHSR.