Minn. R. agency 144, ch. 4659, pt. 4659.0150

Current through Register Vol. 49, No. 24, December 9, 2024

Part 4659.0150 - UNIFORM ASSESSMENT TOOL

Subpart 1.Definition. For purposes of this part "Uniform Assessment Tool" means an assessment tool that meets the requirements of this part and is used by a licensee to comprehensively evaluate a residents or prospective residents physical and cognitive needs.

Subp. 2Assessment tool elements. Each facility must develop a uniform assessment tool. The facility may use any acceptable form or format for the tool, such as an online or a hard-copy paper assessment tool, as long as the tool includes the elements identified in this subpart. A uniform assessment tool must address the following:

A. the residents personal lifestyle preferences, including:

(1) sleep schedule, dietary and social needs, leisure activities, and any other customary routine that is important to the residents quality of life;

(2) spiritual and cultural preferences; and

(3) advance health care directives and end-of-life preferences, including whether a person has or wants to seek a "do not resuscitate" order and "do not attempt resuscitation order" or "physician/provider orders for life sustaining treatment" order;

B. activities of daily living, including:

(1) toileting pattern, bowel, and bladder control;

(2) dressing, grooming, bathing, and personal hygiene;

(3) mobility, including ambulation, transfers, and assistive devices; and

(4) eating, dental status, oral care, and assistive devices and dentures, if applicable;

C. independent activities of daily living, including:

(1) ability to self manage medications;

(2) housework and laundry; and

(3) transportation;

D. physical health status, including:

(1) a review of relevant health history and current health conditions including medical and nursing diagnoses;

(2) allergies and sensitivities related to medication, seasonality, environment, and food and if any of the allergies or sensitivities are life threatening;

(3) infectious conditions;

(4) a review of medications according to Minnesota Statutes, section 144G.71, subdivision 2, including prescriptions, over-the-counter medications, and supplements, and for each:

(a) the reason taken;

(b) any side effects, contraindications, allergic or adverse reactions, and actions to address these issues;

(c) dosage;

(d) frequency of use;

(e) route administered or taken;

(f) any difficulties the resident faces in taking the medication;

(g) whether the resident self administers the medication;

(h) the residents preferences in how to take medication;

(i) interventions needed in management of medications to prevent diversion of medication by the resident or others who may have access to the medications; and

(j) provide instructions to the resident and residents legal or designated representatives on interventions to manage the residents medications and prevent diversion of medications;

(5) a review of medical, dental, and emergency room visits in the past 12 months, including visits to a primary health care provider, hospitalizations, surgeries, and care from a postacute care facility;

(6) a review of any reports from a physical therapist, occupational therapist, speech therapist, or cognitive evaluations within the last 12 months;

(7) weight; and .

(8) initial vital signs if indicated by health conditions or medications;

E. emotional and mental health conditions, including:

(1) review of history of and any diagnoses of mood disorders including depression, anxiety, bipolar disorder, and thought or behavioral disorders;

(2) current symptoms of mental health conditions and behavioral expressions of concerns; and

(3) effective medication treatment and nonmedication interventions;

F. cognition, including:

(1) review of any neurocognitive evaluations and diagnoses; and

(2) current memory, orientation, confusion, and decision-making status and ability;

G. communication and sensory capabilities, including:

(1) hearing;

(2) vision;

(3) speech;

(4) assistive communication and sensory devices including hearing aids; and

(5) the ability to understand and be understood;

H. pain, including:

(1) location, frequency, intensity, and duration; and

(2) effectiveness of medication and nonmedication alternatives;

I. skin conditions;

J. nutritional and hydration status and preferences;

K. list of treatments, including type, frequency, and level of assistance needed;

L. nursing needs, including potential to receive nursing-delegated services;

M. risk indicators, including:

(1) risk for falls including history of falls;

(2) emergency evacuation ability;

(3) complex medication regimen;

(4) risk for dehydration including history of urinary tract infections and current fluid intake pattern;

(5) risk for emotional or psychological distress due to personal losses;

(6) unsuccessful prior placements;

(7) elopement risk including history or previous elopements;

(8) smoking, including the ability to smoke without causing bums or injury to the resident or others or damage to property; and

(9) alcohol and drug use, including the residents alcohol use or drug use not prescribed by a physician;

N. who has decision-making authority for the resident, including:

(1) the presence of any advance health care directive or other legal document that establishes a substitute decision maker; and

(2) the scope of decision-making authority of a substitute decision maker under subitem (1); and

O. the need for follow-up referrals for additional medical or cognitive care by health professionals.

Subp. 3.Record keeping. Assessment tool results, including those from an assessment supplement, must be maintained in the residents record as required under Minnesota Statutes, section 144G.43.

Subp. 4.Licensee attestation. An applicant for an assisted living facility license or a licensee renewing an assisted living facility license must attest to the commissioner in a manner determined by the commissioner that the uniform assessment tool used by the applicant or licensee complies with this part.

Subp. 5.Department access to uniform assessment tool. At the time of a survey, investigation, or other licensing activity, the licensee must provide the department access to or copy of the uniform assessment tool as required under Minnesota Statutes, section 144G.30, subdivision 4, to verify the compliance with this part.

Minn. R. agency 144, ch. 4659, pt. 4659.0150

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