0214 Evaluation – Deficiency
410 IAC 16.2-5-2(a)
(a) An evaluation of the individual needs of each resident shall be initiated prior to
admission and shall be updated at least semiannually and upon a known substantial
change in the resident ‘ s condition, or more often at the resident ‘ s or facility ‘ s
request. A licensed nurse shall evaluate the nursing needs of the resident.
0215 Evaluation – Deficiency
410 IAC 16.2-5-2(b)
(b) The preadmission evaluation (interview) shall provide the baseline information
for the initial evaluation. Subsequent evaluations shall compare the resident ‘ s
current status to his or her status on admission and shall be used to assure that the care
the resident requires is within the range of personal care and supervision provided by
a residential care facility.
0216 Evaluation – Noncompliance
(c) The scope and content of the evaluation shall be delineated in the facility policy
manual, but at a minimum, the needs assessment shall include an evaluation of the
(1) The resident’s physical, cognitive, and mental status.
(2) The resident’s independence in the activities of daily living.
(3) The resident’s weight taken on admission and semiannually thereafter.
(4) If applicable, the resident’s ability to self-administer medications.
(d) The evaluation shall be documented in writing and kept in the facility.
0217 Evaluation – Deficiency
410 IAC 16.2-5-2(e)(1-5)
(e) Following completion of an evaluation, the facility, using appropriately trained
staff members, shall identify and document the services to be provided by the facility,
(1) The services offered to the individual resident shall be appropriate to the:
(C) need; and
of the resident.
(2) The services offered shall be reviewed and revised as appropriate and discussed
by the resident and facility as needs or desires change. Either the facility or the
the resident may request a service plan review.
(3) The agreed-upon service plan shall be signed and dated by the resident, and a copy
of the service, a plan shall be given to the resident upon request.
(4) No identification and documentation of services provided is needed if evaluations
subsequent to the initial evaluation indicate no need for a change in services.
(5) If administration of medications or the provision of residential nursing services,
or both, is needed, a licensed nurse shall be involved in identification and
documentation of the services to be provided.