New Resident Assessment

One of the most important elements of admitting a new resident in the initial physical examination by a physician and the assessment your clinical team performs. 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 ADPH has regulated this process, check it out below:

420-5-4-.06 Care of Residents

(2) Medical Examination Record.

(a) Initial Physical Examination. Not more than Assisted Living Facilities 30 days prior to admission of any resident to an assisted living facility, the resident or prospective resident shall be examined by a physician. For purposes of the initial physical examination only, a currently licensed physician in good standing with the Medical Licensure Commission of any state may complete this physical assessment. The physician shall report his or her findings in writing to the facility. In addition to any information otherwise required by the facility’s policies and procedures, and in addition to any other information the physician recommends or believes is pertinent, the initial physical examination record shall contain the following:

  1. All of the physician’s diagnoses, and the resident’s baseline weight and vital signs.
  2. Medication presently prescribed (name, dosage, and strength of drug, frequency, and route of administration).
  3. A statement by the physician that the resident is free of signs and symptoms of infectious skin lesions and diseases that are capable of transmission to other residents through normal resident to resident contact.
  4. Documentation of evaluation for tuberculosis within the previous 12 months.

(b) Annual Physical Examination. In addition to the admission physical examination, each resident shall be examined annually by a physician, and findings from the annual physical examination shall be documented with a copy placed in the resident’s medical examination record. In addition to any other items specified in the facility’s policies and procedures, and in addition to any information deemed necessary, pertinent, or recommended by the resident’s attending physician, the annual physical examination shall contain the following:

  1. The resident’s weight and vital signs.
  2. Changes in diagnoses.
  3. Changes in medications prescribed (name, dosage, and strength of drug, frequency, and route of administration).
  4. Changes in treatment.

(c) Change of Condition Physician Examinations. Changes in the resident’s condition that require a physical examination and result in a change in diagnoses, medications, or treatments shall be reported to the facility and documented in the resident’s medical examination record. In addition to any other items specified in the facility’s policies and procedures, and in addition to any information deemed necessary, pertinent, or recommended by the resident’s treating physician, this physical examination shall contain a listing of the following:

  1. New diagnoses.
  2. Changes in condition.
  3. Changes in medications prescribed (name, dosage, and strength of drug, frequency, and route of administration).
  4. Changes in treatment.

(d) Vaccines. Assisted living facilities shall immunize residents in accordance with current recommended CDC guidelines. Any particular vaccination requirement may be waived or delayed by the State Health Officer in the event of a vaccine shortage.

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