section .0800 - resident assessment and care plan

 

10A NCAC 13F .0801        RESIDENT ASSESSMENT

(a)  An adult care home shall assure that an initial assessment of each resident is completed within 72 hours of admission using the Resident Register.

(b)  The facility shall assure an assessment of each resident is completed within 30 days following admission and at least annually thereafter using an assessment instrument established by the Department or an instrument approved by the Department based on it containing at least the same information as required on the established instrument.  The assessment to be completed within 30 days following admission and annually thereafter shall be a functional assessment to determine a resident's level of functioning to include psychosocial well-being, cognitive status and physical functioning in activities of daily living.  Activities of daily living are bathing, dressing, personal hygiene, ambulation or locomotion, transferring, toileting and eating.  The assessment shall indicate if the resident requires referral to the resident's physician or other licensed health care professional, provider of mental health, developmental disabilities or substance abuse services or community resource.

(c)  The facility shall assure an assessment of a resident is completed within 10 days following a significant change in the resident's condition using the assessment instrument required in Paragraph (b) of this Rule.  For the purposes of this Subchapter, significant change in the resident's condition is determined as follows:

(1)           Significant change is one or more of the following:

(A)          deterioration in two or more activities of daily living;

(B)          change in ability to walk or transfer;

(C)          change in the ability to use one's hands to grasp small objects;

(D)          deterioration in behavior or mood to the point where daily problems arise or relationships have become problematic;

(E)           no response by the resident to the treatment for an identified problem;

(F)           initial onset of unplanned weight loss or gain of five percent of body weight within a 30-day period or 10 percent weight loss or gain within a six-month period;

(G)          threat to life such as stroke, heart condition, or metastatic cancer;

(H)          emergence of a pressure ulcer at Stage II, which is a superficial ulcer presenting an abrasion, blister or shallow crater, or higher;

(I)            a new diagnosis of a condition likely to affect the resident's physical, mental, or psychosocial well-being such as initial diagnosis of Alzheimer's disease or diabetes;

(J)            improved behavior, mood or functional health status to the extent that the established plan of care no longer matches what is needed;

(K)          new onset of impaired decision-making;

(L)           continence to incontinence or indwelling catheter; or

(M)         the resident's condition indicates there may be a need to use a restraint and there is no current restraint order for the resident.

(2)           Significant change is not any of the following:

(A)          changes that suggest slight upward or downward movement in the resident's status;

(B)          changes that resolve with or without intervention;

(C)          changes that arise from easily reversible causes;

(D)          an acute illness or episodic event;

(E)           an established, predictive, cyclical pattern; or

(F)           steady improvement under the current course of care.

(d)  If a resident experiences a significant change as defined in Paragraph (c) of this Rule, the facility shall refer the resident to the resident's physician or other appropriate licensed health professional such as a mental health professional, nurse practitioner, physician assistant or registered nurse in a timely manner consistent with the resident's condition but no longer than 10 days from the significant change, and document the referral in the resident's record.  Referral shall be made immediately when significant changes are identified that pose an immediate risk to the health and safety of the resident, other residents or staff of the facility.

(e)  The assessments required in Paragraphs (b) and (c) of this Rule shall be completed and signed by the person designated by the administrator to perform resident assessments.

 

History Note:        Authority G.S. 131D-2; 131D-4.5; 143B-165; S.L. 1999-0334;

Temporary Adoption Eff. January 1, 1996;

Eff. May 1, 1997;

Temporary Amendment Eff. September 1, 2003; July 1, 2003;

Amended Eff. July 1, 2005; June 1, 2004.