Section R9-10-414. Comprehensive Assessment; Care Plan

A.      A director of nursing shall ensure that:

1.        A comprehensive assessment of a resident:

a.         Is conducted or coordinated by a registered nurse in collaboration with an interdisciplinary team;

b.        Is completed for the resident within 14 calendar days after the resident’s admission to a nursing care insti- tution;

c.         Is updated:

i.         No later than 12 months after the date of the resident’s last comprehensive assessment, and

ii.        When   the  resident  experiences  a  significant change;

d.        Includes the following information for the resident:

i.         Identifying information;

ii.        An evaluation of the resident’s hearing, speech, and vision;

iii.      An evaluation of the resident’s ability to under- stand and recall information;

iv.       An evaluation of the resident’s mental status;

v.        Whether the resident’s mental status or behav- iors:

(1)     Put the resident at risk for physical illness or injury,

(2)     Significantly interfere with the resident’s care,

(3)     Significantly interfere with the resident’s ability to participate in activities or social interactions,

(4)     Put other residents or personnel members at significant risk for physical injury,

(5)     Significantly intrude on another resident’s privacy, or

(6)     Significantly disrupt care for another resi- dent;

vi.       Preferences for customary routine and activi- ties;

vii.     An evaluation of the resident’s ability to per- form activities of daily living;

viii.    Need for a mobility device;

ix.       An evaluation of the resident’s ability to control the resident’s bladder and bowels;

x.        Any diagnosis that impacts nursing care institu- tion services that the resident may require;

xi.       Any medical conditions that impact the resi- dent’s functional status, quality of life, or need for nursing care institution services;

xii.     An evaluation of the resident’s ability to main- tain adequate nutrition and hydration;

xiii.    An evaluation of the resident’s oral and dental status;

xiv.    An evaluation of the condition of the resident’s skin;

xv.      Identification of any medication or treatment administered to the resident during a seven-day calendar period that includes the time the com- prehensive assessment was conducted;

xvi.    Identification of any treatment or medication ordered for the resident;

xvii.   Whether any restraints have been used for the resident during a seven-day calendar  period that includes the time the comprehensive assessment was conducted;

xviii.A description of the resident or resident’s rep- resentative’s participation in the comprehensive assessment;

xix.    The name and title of the interdisciplinary team members who participated in the resident’s comprehensive assessment;

xx.      Potential for rehabilitation; and

xxi.    Potential for discharge; and

e.         Is signed and dated by:

i.         The registered nurse who conducts or coordi- nates the comprehensive assessment or review; and

ii.        If a behavioral health professional is required to review according to subsection (A)(2), the behavioral health professional who reviewed the comprehensive assessment or review;

2.        If any of the conditions in (A)(1)(d)(v) are answered in the affirmative during the comprehensive assessment or review, a behavioral health professional reviews a resi- dent’s comprehensive assessment or review and care plan to ensure that the resident’s needs for behavioral health services are being met;

3.        A new comprehensive assessment is not required for a resident who is hospitalized and readmitted to a nursing care institution unless a physician, an individual desig- nated by the physician, or a registered nurse determines the resident has a significant change in condition; and

4.        A resident's comprehensive assessment is reviewed by a registered nurse at least once every three months after the date of the current comprehensive assessment and if there is a significant change in the resident's condition.

B.       An administrator shall ensure that a care plan for a resident:

1.        Is developed, documented, and implemented for the resi- dent within seven calendar days after completing the resi- dent’s comprehensive assessment required in subsection (A)(1);

2.        Is reviewed and revised based on any change to the resi- dent’s comprehensive assessment; and

3.        Ensures that a resident is provided nursing care institution services that:

a.         Address any medical condition or behavioral health issue identified in the resident’s comprehensive assessment, and

b.        Assist the resident in maintaining the resident's highest practicable well-being according to the resi- dent's comprehensive assessment.

Historical Note

Adopted effective January 28, 1980 (Supp. 80-1). Section repealed by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). New Section R9-10-414 made by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2). Section repealed; new Sec- tion made by exempt rulemaking at 19 A.A.R. 3334, effective October 1, 2013 (Supp. 13-4). Amended by exempt rulemaking at 20 A.A.R. 1409, pursuant to Laws 2013, Ch. 10, § 13; effective July 1, 2014 (Supp. 14-2).