The initial resident evaluation
When considering admitting a prospective resident to your community, you must perform a resident assessment to determine if you can perform the care this resident will require. Many facilities will allow a resident to move in who they cannot care for due to low census among many other factors. Preforming this RCFL required assessment prior to admission will ensure the relationship with be cohesive for all parties. Using this resident assessment will assist with developing an individual service plan and building the care needs that the resident requires. Take a look below for what the Indiana Residential Care Facility Licensing Program requires from the resident assessment:
410 IAC 16.2-5-2 Evaluation
- 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.
- 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.
- 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 following:
(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.
(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, as follows:
(1) The services offered to the individual resident shall be appropriate to the:
(A) scope;
(B) frequency;
(C) need; and
(D) preference; 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 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 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.
Top Takeaways:
- (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.
Anytime RCFL puts a time frame to a regulation you should be sure to meet the requirement. The initial resident assessment needs to be conducted prior to the resident admitting to the community. This covers the facility in so many ways, most importantly if you admit a resident you cannot care for the facility is at risk and will need to find alternate placement.
- (d) 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 following:
(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.
The initial assessment is a comprehensive assessment designed to investigate and address the functional and cognitive needs of each resident. You will be tasked with including all of the required documentation in order to have an accurate depiction of the residents needs.