Utah Admin. Code R432-150-12 - Resident Assessment

(1) The licensee shall, upon resident admission, obtain physician orders for the resident's immediate care.

(2) The licensee shall:

(a) complete a comprehensive assessment of each resident's needs including a description of the resident's capability to perform daily life functions and significant impairments in functional capacity that includes:

(i) activities potential;

(ii) cognitive status;

(iii) dental condition;

(iv) discharge potential;

(v) drug therapy;

(vi) medical status measurement;

(vii) medically defined conditions and prior medical history;

(viii) mental and psychosocial status;

(ix) nutritional status and requirements;

(x) physical and mental functional status;

(xi) rehabilitation potential;

(xii) sensory and physical impairments; and

(xiii) special treatments or procedures;

(b) complete three quarterly reviews and one full assessment in each 12-month period;

(c) ensure that a resident care conference is conducted when there is any significant change in a resident's physical or mental health and the team may require a new assessment within 14 days of the condition change;

(d) ensure the initial assessment is completed within 14 calendar days of admission and any revisions to the initial assessment are completed within 21 calendar days of admission; and

(e) use the results of the assessment to develop, review, and revise the resident's comprehensive care plan.

(3) The licensee shall ensure each individual who completes a portion of the assessment signs and certifies the accuracy of that portion of the assessment.

(4) The licensee shall develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs as identified in the comprehensive assessment.

(5) The licensee shall ensure the comprehensive care plan is:

(a) developed within seven days after completion of the comprehensive assessment;

(b) periodically reviewed and revised by a team of qualified individuals at least after each assessment and as the resident's condition changes; and

(c) prepared with input from the client, the resident's responsible person to the extent practicable, and a resident care conference that includes:

(i) the attending physician;

(ii) the registered nurse responsible for the resident; and

(iii) other appropriate staff in disciplines determined by the resident's needs.

(6) The licensee shall ensure the services provided or arranged meet professional standards of quality and be provided by qualified persons in accordance with the resident's written care plan.

(7)

(a) The licensee shall ensure a final summary of the resident's status, to include items in Subsection R432-150-13(2)(a), is prepared at the time of discharge and is available for release to authorized persons and agencies, with the consent of the resident or responsible person.

(b) The licensee shall ensure the final summary includes a post-discharge care plan developed with the participation of the resident and resident's family or guardian.

(c) If the licensee discharges a resident because they cannot meet the resident's needs, the licensee shall include a detailed explanation of why the resident's needs could not be met in the final summary.

Notes

Utah Admin. Code R432-150-12

Amended by Utah State Bulletin Number 2017-12, effective 5/16/2017 Amended by Utah State Bulletin Number 2024-01, effective 12/12/2023 Amended by Utah State Bulletin Number 2025-05, effective 2/18/2025