La. Admin. Code tit. 50 § II-10123

Current through Register Vol. 50, No. 11, November 20, 2024

Section II-10123 - Comprehensive Assessment

A. The facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity and needs, in relation to a number of specified areas. Comprehensive assessments must:

1. be based on a uniform data set (resident assessment instrument); and

2. describe the resident's capability to perform daily life functions and significant impairments in functional capacity;

3. include the following information:

a. medically defined conditions and prior medical treatment;

b. medical status measurements;

c. physical and mental functional status;

d. sensory and physical impairments;

e. nutritional status and requirements;

f. special treatment and procedures;

g. mental and psychosocial status;

h. discharge potential;

i. dental condition;

j. activities potential;

k. rehabilitation potential;

l. cognitive status; and

m. drug therapy.

B. Frequency. The assessment must be conducted no later than 14 days after admission for new admissions.

1. A reassessment must be completed after a significant change in the resident's physical and/or mental condition.

2. A reassessment must be conducted at least once every 12 months/annually.

3. Residents must be examined and assessments must be reviewed every three months and revised as appropriate to assure the continued accuracy of the assessment.

C. Coordination of Assessments with Pre-admission Screening. The facility must coordinate assessments with the state-required pre-admission screening program to the maximum extent practicable to avoid duplicate testing and effort.

D. Accuracy of Assessments. To assure accuracy, the assessments:

1. must be conducted or coordinated with the appropriate participation of health professional;

2. must be conducted or coordinated by a registered nurse who signs and certifies completion of the assessment; and

3. must have each individual who completes a portion of the assessment sign and certify the accuracy of that portion of the assessment.

E. Penalty for Falsification

i. Any individual who willfully and knowingly certifies (or causes another individual to certify) a material and false statement is subject to civil money penalties.

ii. Clinical disagreement does not constitute a material and false statement.

iii. If the state determines under survey, or otherwise, that there has been knowing and willful certification of false statements, the state may require that the residents' assessments be conducted by individuals independent of the facility. The independent assessors must be approved by the state. The total cost of this independent assessment is the sole responsibility of the facility. Additionally, all independent assessments are not considered necessary expenditures of the facility.

F. Utilization - Resident Assessment Instrument (RAI)

1. Components of comprehensive assessment (RAI):

a. minimum data set (MDS);

b. triggers legend;

c. care area assessment; and

d. utilization guidelines;

e. alteration of MDS information-MDS information collected may be altered until the twenty-first day after admission for the following reasons:

i. information not available to staff completing section because the resident is unable to provide necessary information and family members must make an appointment to participate;

ii. further observation and interaction with the resident reveals a need to alter the assessment;

iii. at admission, the resident's condition is unstable and the illness or chronic problem is controlled by the twenty-first day.

2. If the MDS must be altered up to the twenty-first day, then the assessor shall show these changes on the admission assessment and shall initial and date such amendments.

3. The MDS may not be altered after the twenty-first day. If a change has occurred, a new MDS must be completed.

4. Significant change defined:

a. deterioration in two or more activities of daily living, communication, and/or cognitive abilities that appear permanent;

b. loss of ability to freely ambulate or to use hands to grasp a small object to feed or groom oneself, such as spoon, toothbrush or comb;

c. deterioration in behavior, mood, and/or relationships that has not been reversed;

d. deterioration in a resident's health status where this change places the resident's life in danger, is associated with serious clinical complications, or is associated with an initial new diagnosis of a condition that is likely to affect the resident's physical, mental, or psychosocial well-being over a prolonged period of time;

e. onset of a significant weight loss (five percent in last 30 days or ten percent in last 180 days); and

f. a marked and sudden improvement in the resident's status.

5. Document in medical record the initial identification of a significant change in status. Once it has been determined that the resident's change in status is likely to be permanent, complete a full comprehensive assessment within 14 days of that determination.

6. Quarterly Assessment and Optional Progress Notes-to track resident status between assessments and to ensure monitoring of critical indicators of the gradual onset of significant declines in resident status, a registered nurse:

a. must examine the resident;

b. review the MDS core elements as outlined in the HSS Form Quarterly RA Review:

i. Section B - Items 2 and 4;

ii. Section C - Items 4 and 5;

iii. Section E - Items 1 b-f and 3A;

iv. Section F - Item 1;

v. Section J - Note only disease diagnosis in last 90 days;

vi. Section L - Item 2C;

vii. Section O - Item 4;

viii. Section P - Item 3;

7. Triggers-Level of measurement (coding categories) of MDS elements that identify residents who require evaluation using the care area assessment (CAA) process.

8 - 8.g. Repealed.

G. Care Area Assessment (CAA) Process and Care Planning

1. CAAs are triggered responses to items coded on the MDS specific to a resident's possible problems, needs or strengths.

2. The CAA process provides:

a. a framework for guiding the review of triggered areas;

b. clarification of a resident's functional status and related causes of impairments; and

c. a basis for additional assessment of potential issues, including related risk factors.

3. The CAA must:

a. be conducted or coordinated by a registered nurse (RN) with the appropriate participation of health professionals;

b. have input that is needed for clinical decision making (e.g., identifying causes and selecting interventions) that is consistent with relevant clinical standards of practice; and

c. address each care area identified under CMS's RAI Version 3.0 Manual, section 4.10, Table 10 (The Twenty Care Areas).

4. CAA documentation should indicate:

a. the basis for decision making;

b. why the finding(s) require(s), or does not require, an intervention; and

c. the rationale(s) for selecting specific interventions.

H. Effective for assessments with assessment reference dates of October 1, 2023 and after, the department mandates the use of the optional state assessment (OSA) item set. The OSA item set is required to be completed in conjunction with each assessment and at each assessment interval detailed within this Section. The OSA item set must have an assessment reference date that is identical to that of the assessment it was performed in conjunction with.

La. Admin. Code tit. 50, § II-10123

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 22:34 (January 1996), Amended by the Department of Health, Bureau of Health Services Financing, LR 46695 (5/1/2020), Amended LR 461684 (12/1/2020), Amended LR 50(EMERGENCY), Amended LR 50219 (2/1/2024).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:153 and R.S. 46:2742.