Or. Admin. Code § 411-054-0034 - Resident Move-In and Evaluation
(1) INITIAL SCREENING AND MOVE-IN.
(a) The facility must determine whether a
potential resident meets the facility's admission requirements.
(b) Before the resident moving in, the
facility must conduct an initial screening to determine the prospective
resident's service needs and preferences. The screening must determine the
ability of the facility to meet the potential resident's needs and preferences,
including evaluating staff time required to meet estimated acuity needs for the
resident, while considering the needs of the other residents and the facility's
overall service capability.
(c)
Each resident record must, before move-in and when updated, include the
following information:
(A) Legal name for
billing purposes.
(B) To promote
person-centered care, any variance from legal records, as indicated by the
resident, regarding:
(i) Name.
(ii) Pronouns.
(iii) Gender identity.
(C) Prior living arrangements;
(D) Emergency contacts;
(E) Service plan involvement - resident,
family, and social supports;
(F)
Financial and other legal relationships, if applicable, including, but not
limited to:
(i) Advance directives;
(ii) Guardianship;
(iii) Conservatorship; and
(iv) Power of attorney.
(G) Primary language;
(H) Community connections; and
(I) Health and social service
providers.
(2) RESIDENT EVALUATION - GENERAL. The
resident evaluation identifies the resident's preferences, strengths, and
relationships, as well as activities that are meaningful to the individual. The
evaluation describes the resident's physical health status, mental status, and
the environmental factors that help the individual function at their optimal
level. The evaluation is the foundation that a facility uses to develop the
resident's service plan. The evaluation information may be collected using
tools and protocols established by the facility, but must contain the elements
stated in this rule.
(a) Resident evaluations
must be:
(A) Performed before the resident
moves into the facility, with updates and changes as appropriate within the
first 30 days; and
(B) Performed at
least quarterly, to correspond with the quarterly service plan
updates.
(C) Reviewed and any
updates must be documented each time a resident has a significant change in
condition.
(D) Done in person and
the facility must gather data that is relevant to the needs and current
condition of the resident.
(E)
Documented, dated, and indicate who was involved in the evaluation
process.
(b) 24 months
of past evaluations must be kept in the resident's files in an accessible,
on-site location.
(c) The facility
administrator is responsible for assuring only trained and experienced staff
perform resident evaluations.
(3) EVALUATION REQUIREMENTS AT MOVE-IN.
(a) The resident evaluation must be completed
before the resident moves into the facility. This evaluation provides baseline
information of the resident's physical and mental condition at
move-in.
(b) If there is an urgent
need and the evaluation is not completed before move-in, the facility must
document the reasons and complete the evaluation within eight hours of
move-in.
(c) The initial evaluation
must contain the elements specified in section (5) of this rule and address
sufficient information to develop an initial service plan to meet the
resident's needs.
(d) The initial
evaluation must be updated and modified as needed during the 30 days following
the resident's move into the facility.
(e) After the initial 30 day move-in period,
the initial evaluation must be retained in the resident's file for 24 months.
Future evaluations must be separate and distinct from the initial
evaluation.
(4)
QUARTERLY EVALUATION REQUIREMENTS.
(a)
Resident evaluations must be performed quarterly after the resident moves into
the facility.
(b) The quarterly
evaluation is the basis of the resident's quarterly service plan.
(c) The most recent quarterly evaluation,
with documented change of condition updates, must be in the resident's current
record and available to staff.
(d)
If the evaluation is revised and updated at the quarterly review, changes must
be dated and initialed and prior historical information must be
maintained.
(5) The
resident evaluation must address the following elements:
(a) For service planning purposes, if
indicated by the resident,
(A) Name.
(B) Pronouns.
(C) Gender identity.
(b) Resident routines and preferences
including:
(A) Customary routines, such as
those related to sleeping, eating, and bathing;
(B) Interests, hobbies, and social and
leisure activities;
(C) Spiritual
and cultural preferences and traditions; and
(D) Additional elements as listed in
411-054-0027(2).
(c) Physical health status
including:
(A) List of current
diagnoses;
(B) List of medications
and PRN use;
(C) Visits to health
practitioners, emergency room, hospital, or nursing facility in the past year;
and
(D) Vital signs if indicated by
diagnoses, health problems, or medications.
(d) Mental health issues including:
(A) Presence of depression, thought
disorders, or behavioral or mood problems;
(B) History of treatment; and
(C) Effective non-drug
interventions.
(e)
Cognition, including:
(A) Memory;
(B) Orientation;
(C) Confusion; and
(D) Decision-making abilities.
(f) Personality, including how the
person copes with change or challenging situations.
(g) Communication and sensory abilities
including:
(A) Hearing;
(B) Vision;
(C) Speech;
(D) Use of assistive devices; and
(E) Ability to understand and be
understood.
(h)
Activities of daily living including:
(A)
Toileting, bowel, and bladder management;
(B) Dressing, grooming, bathing, and personal
hygiene;
(C) Mobility - ambulation,
transfers, and assistive devices; and
(D) Eating, dental status, and assistive
devices.
(i) Independent
activities of daily living including:
(A)
Ability to manage medications;
(B)
Ability to use call system;
(C)
Housework and laundry; and
(D)
Transportation.
(j) Pain
- pharmaceutical and non-pharmaceutical interventions, including how a person
expresses pain or discomfort.
(k)
Skin condition.
(l) Nutrition
habits, fluid preferences, and weight if indicated.
(m) List of treatments - type, frequency, and
level of assistance needed.
(n)
Indicators of nursing needs, including potential for delegated nursing
tasks.
(o) Review of risk
indicators including:
(A) Fall risk or
history;
(B) Emergency evacuation
ability;
(C) Complex medication
regimen;
(D) History of dehydration
or unexplained weight loss or gain;
(E) Recent losses;
(F) Unsuccessful prior placements;
(G) Elopement risk or history;
(H) Smoking. The resident's ability to smoke
without causing burns or injury to themselves or others or damage to property
must be evaluated and addressed in the resident's service plan; and
(I) Alcohol and drug use. The resident's use
of alcohol or the use of drugs not prescribed by a physician must be evaluated
and addressed in the resident's service plan.
(p) Environmental factors that impact the
resident's behavior including, but not limited to:
(A) Noise.
(B) Lighting.
(C) Room temperature.
(6) If the information has not
changed from the previous evaluation period, the information does not need to
be repeated. A dated and initialed notation of no changes is sufficient. The
prior evaluation must then be kept in the current resident record for
reference.
Notes
Statutory/Other Authority: ORS 410.070, 441.122 & 443.450
Statutes/Other Implemented: ORS 441.111, 441.114, 443.400 - 443.455 & 443.991
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