Utah Admin. Code 432-150-13

Current through Bulletin No. 2024-21, November 1, 2024

Section R432-150-13 - 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 the following:

(i) medically defined conditions and prior medical history;

(ii) medical status measurement;

(iii) physical and mental functional status;

(iv) sensory and physical impairments;

(v) nutritional status and requirements;

(vi) special treatments or procedures;

(vii) mental and psychosocial status;

(viii) discharge potential;

(ix) dental condition;

(x) activities potential;

(xi) rehabilitation potential;

(xii) cognitive status; and

(xiii) drug therapy;

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

(c) ensure that an interdisciplinary team review 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) complete three quarterly reviews and one full assessment in each 12-month period; 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) prepared with input from an interdisciplinary team that includes the attending physician, the registered nurse having responsibility for the resident, and other appropriate staff in disciplines determined by the resident's needs, and with the participation of the resident, and the resident's family or guardian, to the extent practicable; and

(c) periodically reviewed and revised by a team of qualified persons at least after each assessment and as the resident's condition changes.

(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 representative.

(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.

Utah Admin. Code R432-150-13

Amended by Utah State Bulletin Number 2024-01, effective 12/12/2023