Or. Admin. Code § 411-054-0034

Current through Register Vol. 63, No. 12, December 1, 2024

Section 411-054-0034 - [Effective 12/27/2024] Resident Move-In and Evaluation

(1) INITIAL SCREENING AND MOVE-IN.

(a) The facility must determine whether a potential resident meets the facility's admission requirements.

(b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability.

(c) Each resident record must, before move-in and when updated, include the following information:

(A) Legal name for billing purposes.

(B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding:

(i) Name.

(ii) Pronouns.

(iii) Gender identity.

(C) Prior living arrangements;

(D) Emergency contacts;

(E) Service plan involvement - resident, family, and social supports;

(F) Financial and other legal relationships, if applicable, including, but not limited to:

(i) Advance directives;

(ii) Guardianship;

(iii) Conservatorship; and

(iv) Power of attorney.

(G) Primary language;

(H) Community connections; and

(I) Health and social service providers.

(2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule.

(a) Resident evaluations must be:

(A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and

(B) Performed at least quarterly, to correspond with the quarterly service plan updates.

(C) Reviewed and any updates must be documented each time a resident has a significant change in condition.

(D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident.

(E) Documented, dated, and indicate who was involved in the evaluation process.

(b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location.

(c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations.

(3) EVALUATION REQUIREMENTS AT MOVE-IN.

(a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in.

(b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in.

(c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs.

(d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility.

(e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation.

(4) QUARTERLY EVALUATION REQUIREMENTS.

(a) Resident evaluations must be performed quarterly after the resident moves into the facility.

(b) The quarterly evaluation is the basis of the resident's quarterly service plan.

(c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff.

(d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained.

(5) The resident evaluation must address the following elements:

(a) For service planning purposes, if indicated by the resident,

(A) Name.

(B) Pronouns.

(C) Gender identity.

(b) Resident routines and preferences including:

(A) Customary routines, such as those related to sleeping, eating, and bathing;

(B) Interests, hobbies, and social and leisure activities;

(C) Spiritual and cultural preferences and traditions; and

(D) Additional elements as listed in 411-054-0027(2).

(c) Physical health status including:

(A) List of current diagnoses;

(B) List of medications and PRN use;

(C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and

(D) Vital signs if indicated by diagnoses, health problems, or medications.

(d) Mental health issues including:

(A) Presence of depression, thought disorders, or behavioral or mood problems;

(B) History of treatment; and

(C) Effective non-drug interventions.

(e) Cognition, including:

(A) Memory;

(B) Orientation;

(C) Confusion; and

(D) Decision-making abilities.

(f) Personality, including how the person copes with change or challenging situations.

(g) Communication and sensory abilities including:

(A) Hearing;

(B) Vision;

(C) Speech;

(D) Use of assistive devices; and

(E) Ability to understand and be understood.

(h) Activities of daily living including:

(A) Toileting, bowel, and bladder management;

(B) Dressing, grooming, bathing, and personal hygiene;

(C) Mobility - ambulation, transfers, and assistive devices; and

(D) Eating, dental status, and assistive devices.

(i) Independent activities of daily living including:

(A) Ability to manage medications;

(B) Ability to use call system;

(C) Housework and laundry; and

(D) Transportation.

(j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.

(k) Skin condition.

(l) Nutrition habits, fluid preferences, and weight if indicated.

(m) List of treatments - type, frequency, and level of assistance needed.

(n) Indicators of nursing needs, including potential for delegated nursing tasks.

(o) Review of risk indicators including:

(A) Fall risk or history;

(B) Emergency evacuation ability;

(C) Complex medication regimen;

(D) History of dehydration or unexplained weight loss or gain;

(E) Recent losses;

(F) Unsuccessful prior placements;

(G) Elopement risk or history;

(H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and

(I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan.

(p) Environmental factors that impact the resident's behavior including, but not limited to:

(A) Noise.

(B) Lighting.

(C) Room temperature.

(6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference.

Or. Admin. Code § 411-054-0034

SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07; SPD 13-2009, f. 9-30-09, cert. ef. 10-1-09; SPD 11-2012, f. 8-31-12, cert. ef. 9-1-12; APD 10-2016, f. 6-27-16, cert. ef. 6/28/2016; APD 30-2019, amend filed 08/19/2019, effective 9/1/2019; APD 28-2024, temporary amend filed 06/21/2024, effective 7/1/2024 through 12/27/2024; APD 57-2024, amend filed 09/23/2024, effective 9/25/2024

Statutory/Other Authority: ORS 410.070, 441.122 & 443.450

Statutes/Other Implemented: ORS 441.111, 441.114, 443.400 - 443.455 & 443.991