ASSESSMENT

FOR  CARE  PLANNING

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    The successful care of residents requires a comprehensive evaluation of their current condition and care needs.  This assessment is required to provide the facility with ongoing information necessary to develop a care plan, to provide the appropriate care and services for each resident, and to modify the care plan and care/services based on the resident’s admissions status or change in condition.


                                                 

PAGE CONTENTS

            ∆  Screening for mental illness or retardation.

            ∆  Assessment requirements.

            ∆  Timing of assessments.

            ∆  Accuracy of assessment.

            ∆  Medicare assessments.

            ∆  Coordination and certification of the assessment.



  ∆  Screening for mental illness or retardation.

   Pre-admission screening is done outside the facility to ensure that individuals with mental illness and mental retardation receive the care and services they need in the most appropriate setting.  People with either of the two conditions may be found to be inappropriate for admission to the facility because specialized care they require is not available at that site.


    Under the Pre-Admission Screening and Resident Review (PASRR), the State is responsible for conducting the screens, preparing the PASRR report, and providing or arranging the specialized services that are needed as indicated by the screens. All other needed services are the responsibility of the facility to care plan for and provide.


  Assessment requirements.

    Regulations require that: The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident’s functional capacity.


    The facility is expected to use observation of and communication with the resident as the primary source of information when completing the assessment form.  In addition to direct observation and communication with the resident, the facility should use a variety of other sources, including communication with licensed and non-licensed staff members on all shifts and may include discussions with the resident’s physician, family members, or outside consultants and review of the resident’s health history.

    Each facility must use its State-specified form to assess newly admitted residents, conduct an annual reassessment, and assess those residents who experience a significant change in condition. The facility is responsible for addressing all needs and strengths of residents. The scope of the form does not limit the facility’s responsibility to assess and address all care needed by the resident, not just those on the list below.


    The assessment must include at least the following.

  1. (i)Identification and demographic information - the information that uniquely identifies each resident and the facility in which he/she resides, date of entry into the facility, and residential history.


  1. (ii)Customary routine - the information regarding the resident’s usual community lifestyle and daily routine.


  1. (iii)Cognitive patterns - the resident’s ability to problem solve, decide, remember, and be aware of and respond to safety hazards.


  1. (iv)Communication - the resident’s ability to hear, understand others, and/or make him or herself understood with assistive devices if they are used.


  1. (v)Vision - the resident’s visual acuity, limitations and difficulties, and appliances used to enhance vision.


  1. (vi) Mood and behavior patterns - the resident’s patterns of mood and behavioral symptoms.


  1. (vii) Psychosocial well-being - the resident’s positive or negative feelings about him or herself or his/her social relationships.


  1. (viii)Physical functioning and structural problems - the resident’s physical functional status, ability to perform activities of daily living, and the resident’s need for staff assistance and assistive devices or equipment to maintain or improve functional abilities.


  1. (ix)Continence - the resident’s patterns of bladder and bowel continence or control, pattern of elimination, and appliances used.


  1. (x)Disease diagnosis and health conditions - (No definition provided.)


(xi) Dental and nutritional status:

    * Dental condition status refers to the condition of the teeth, gums, and other structures of the oral

      cavity that may affect a resident’s nutritional status, communication abilities, or quality of life.

      The assessment should include the need for, and use of, dentures or other dental appliances.


    * Nutritional status refers to weight, height, hematologic and biochemical assessments, clinical

      observations of nutrition, nutritional intake, resident’s eating habits and preferences, dietary

       restrictions, supplements, and use of appliances.


  1. (xii) Skin conditions - the resident’s development, or risk of development of a pressure sore.


  1. (xiii)Activity pursuit - the resident’s ability and desire to take part in activities which maintain or

      improve, physical, mental, and psychosocial well-being. Activity pursuits refer to any activity

       outside of activities of daily living which a person pursues in order to obtain a sense of

       well-being. It also includes activities which provide benefits in self-esteem, pleasure, comfort,

       health education, creativity, success, and financial or emotional independence. The assessment

        should consider the resident’s normal everyday routines and lifetime preferences.


  1. (xiv)Medications - all prescription and over-the-counter medications taken by the resident, including dosage, frequency of administration, and recognition of significant side effects that would be most likely to occur in the resident.


  1. (xv) Special treatments and procedures - treatments and procedures that are not part of basic services provided. For example, treatment for pressure sores, naso-gastric feedings, specialized rehabilitation services, respiratory care, or devices and restraints.


  1. (xvi)Discharge potential - the facility’s expectation of discharging the resident from the facility within the next 3 months.


  1. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the MDS - documentation concerning which Care Area Assessment (CAA) have been triggered, documentation of assessment information in support of clinical decision making relevant to the CAAs, documentation regarding where, in the clinical record, information related to the CAAs can be found, and for each triggered CAA, whether the identified problem was included in the care plan.


  1. (xviii)Documentation of participation in assessment - documentation of who participated in the

        assessment process. The assessment process must include direct observation and communication

        with the resident, as well as communication with licensed and non-licensed direct care staff

        members on all shifts.


  Timing of assessments.

 
  At a minimum, residents must be assessed upon admission, when a significant change of condition takes place, and at least annually plus the assessment must be reviewed at least quarterly.  These minimums do not eliminate other assessments if conditions exist making others necessary to maintain a current, appropriate care plan.


   When required, a facility must conduct a comprehensive assessment of a resident as follows:

  1. (i)Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident’s physical or mental condition.  For purposes of this section, readmission means a return to the facility following a temporary absence for hospitalization or therapeutic leave.


  1. (ii)Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition.  For purpose of this section, a significant change means a major decline or improvement in the resident’s status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident’s health status, and requires interdisciplinary review or revision of the care plan, or both.


  1. (iii)Not less than once every 12 months.


    Quarterly Review Assessment - A facility must also assess a resident using the quarterly review instrument . . . not less frequently than once every 3 months.


  ∆  Accuracy of assessment.

    The assessments must be done in such a way that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and knowledgeable about the resident’s status, needs, strengths, and areas of decline.

    An accurate assessment means the appropriate qualified health professional correctly documents the resident’s medical, functional, and psychosocial problems and identifies resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. The initial comprehensive assessment provides baseline data for ongoing assessment of resident progress.


  ∆  Medicare assessments.

   Skilled therapeutic and clinical care covered under Part A Medicare triggers other assessments of the resident’s clinical condition.  An assessment must be completed to determine the residents care needs and progress or lack of progress at day 5, 14, 30, 60, and 90 for care funded by Medicare part A.  An assessment is also necessary when a Medicare qualified resident is readmitted due to break in their stay at the nursing home.


    Medicare Part A covers skilled care for a maximum of 100 days with the last 80 days requiring a co-pay by the resident. Payment rate to the nursing home is based upon the complexity of care needed by the resident.  These required assessments are designed to determine the necessary care level and treatments or that skilled clinical or therapeutic care is no longer needed, which in turn sets the per diem payment to the nursing home for the days covered by the assessment.  Daily Medicare payment rates can vary greatly depending upon the level of care required.  The assessment determines the progress or deterioration of a residents condition.  More importantly for Medicare, the assessment can indicate the individual has reached their maximum level of improvement and no longer requires skilled care.  At that point, the resident’s health can be maintained by custodial care which does not qualify for Medicare coverage.


  ∆  Coordination and certification of the assessment.

   The regulations require that:  A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

  1. (1)A registered nurse must sign and certify that the assessment is completed.

  2. (2)Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.


    According to the guidelines for each State’s assessment form, the physical, mental and psychosocial condition of the resident determines the appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medical social workers, dietitians, and other professionals, such as developmental disabilities specialists, in assessing the resident, and in correcting resident assessments. Involvement of other disciplines is dependent upon resident status and needs, but the registered nurse will conduct and/or coordinate the assessment, as appropriate. Whether conducted or coordinated by the registered nurse, he or she is responsible for certifying that the assessment has been completed.


  

End Note: The majority this section is edited material from Medicare/Medicaid regulation Appendix PP, §483.20 Resident Assessment.  The order of presentation for some material has been changed, information not supporting an understanding of resident assessment in the nursing home was deleted, and wording and organizational changes were made to create an easier to read document.


More information from on these topics, see Appendix PP, §483.20 Resident Assessment at:

www.cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf




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