(A) Each nursing home, in accordance with
this rule, shall require written initial and periodic assessments of all
residents. The different components of the assessment may be performed by
different licensed health care professionals, consistent with the type of
information required and the professional's scope of practice, as defined by
applicable law, and shall be based on personal observation and judgment. This
paragraph does not prohibit the licensed health professional from including in
the assessment resident information obtained by or from unlicensed staff
provided the evaluation of such information is performed by that licensed
health professional in accordance with the applicable scope of
practice.
(B) Prior to admission,
the nursing home shall obtain from the prospective resident's physician, other
appropriate licensed health professionals acting within their applicable scope
of practice, or the transferring entity, the current medical history and
physical of the prospective resident, including the discharge diagnosis,
admission orders for immediate care, the physical and mental functional status
of the prospective resident, and sufficient additional information to assure
care needs of and preparation for the prospective resident can be met. This
information shall have been updated no more than five days prior to
admission.
(C) Upon admission, the
nursing home shall assess each resident in the following areas:
(1) Cardiovascular, pulmonary, neurological
status including auscultation of heart and lung sounds, pulses and vital signs;
and
(2) Hydration and nutritional
status
, including allergies and intolerances;
and
(3) Presenting physical,
psycho-social and mental status.
The nursing home shall also review each resident's admission
orders to determine if the orders are consistent with the resident's status
upon admission as assessed by the nursing home and shall reconfirm, as
applicable, the orders with the attending physician or other licensed health
care professional acting within the applicable scope of practice. The nursing
home shall obtain any special equipment, furniture or staffing that is needed
to address the presenting needs of the resident. The nursing home shall provide
services to meet the specific needs of each resident identified through this
admission assessment until such time as the care plan required by rule
3701-17-14 of the Administrative
Code is developed and implemented.
(D) The nursing home shall perform a
comprehensive assessment meeting the requirements of paragraph (E) of this rule
on each resident as follows:
(1) The
comprehensive assessment shall be performed within fourteen days after the
individual begins to reside in the facility.
(2) Subsequent to the initial comprehensive
assessment, a comprehensive assessment shall be performed at least annually
thereafter. The annual comprehensive assessment shall be performed within
thirty days of the anniversary date of the completion of the resident's last
comprehensive assessment.
(E) The comprehensive assessment shall
include documentation of the following:
(1)
Medical diagnoses
Preferences of the resident including hobbies, usual
activities, bathing, sleeping patterns, socialization and
religious;
(2)
(3) Psychological, and
mental retardation
intellectual disabilities and developmental diagnoses
and history, if applicable;
(3)
(4) Health history and
physical, including cognitive functioning, sensory and physical impairments,
and the risk of falls;
(4)
(5) Psycho-social
history and the preferences of the resident
including hobbies, usual activities, food preferences, bathing preferences,
sleeping patterns, and socialization and religious
preferences;
(5)
(6) Prescription and
over-the-counter medications;
(6)
(7) Nutritional
and dietary requirements
,
food preferences, and need for
any adaptive
equipment, and needs for assistance and supervision of meals;
(7)
(8)
Height
,
and
weight
and history of weight changes;
(8)
(9) A
functional assessment which evaluates the resident's ability to perform
activities of daily living;
(9)
(10) The resident's
risk of falls;
(10)
(11) Vision, dental and hearing function
, including the need for eyeglasses or other visual
aids;
and
(12)
Dental function;
including the need for dentures or partial dentures;
(13)
Hearing
function, including the need for hearing aids or other hearing devices;
and
(11)
(14) Any other alternative remedies and treatments
the resident is taking or receiving.
The documentation required by this paragraph shall include the
name and signature of the individual performing the assessment, or component of
the assessment, and the date the assessment was
completed.
(F)
Subsequent to the initial comprehensive assessment, the nursing home shall
periodically reassess each resident, at minimum, every three months, unless a
change in the resident's physical or mental health or cognitive abilities
requires an assessment sooner. The nursing home shall update and revise the
assessment to reflect the resident's current status. This periodic assessment
shall include documentation of at least the following:
(1) Changes in medical diagnoses;
(2) Updated nutritional requirements and
needs for assistance and supervision of meals;
(3) Height
,
and weight
and
history of weight changes;
(4) Prescription and over-the-counter
medications;
(5) A functional
assessment as described in paragraph (E)(8) of this rule;
(6) The resident's risk of falls;
(7) Any changes in the resident's
psycho-social status or preferences as described in paragraph (E)(4) of this
rule; and
(8) Any changes in
cognitive, communicative or hearing abilities or mood and behavior
patterns.
(G) Nursing
homes that conduct resident assessments in accordance with
42 C.F.R.
483.20, using the resident assessment
instrument specified by rule 5101:3-3-43.1 of the Administrative Code, shall be
considered in compliance with paragraphs (D), (E) and (F) of this
rule.
(H)
Beginning July 1, 2015, each
Each nursing home shall participate in advance
care planning with each resident or the resident's sponsor if the resident is
unable to participate.
For each resident,
the
The advance care planning shall be
provided on admission to the nursing home
or, in the
case of an individual residing in a nursing home on July 1, 2015, as soon as
practicable. Thereafter, for each resident, the advance care planning
shall be provided quarterly each year. For purposes of this paragraph, "advance
care planning" means providing an opportunity to discuss the goals that may be
met through the care provided by a nursing home.