Assessing the Assisted Living Resident
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Within 14 days of admission, a resident
comprehensive assessment and an individual service plan for
providing care, which is based on the comprehensive assessment,
must be completed. The comprehensive assessment must be completed
by the appropriate staff and documented on a form developed by the
facility. When a facility is unable to obtain information required
for the comprehensive assessment, the facility should document its
attempts to obtain the information.
| (1) The comprehensive assessment must
include the following items: |
(A) the location from which the resident was
admitted;
(B) primary language;
(C) sleep-cycle issues;
(D) behavioral symptoms;
(E) psychosocial issues (i.e., a psychosocial functioning
assessment that includes an assessment of mental or psychosocial
adjustment difficulty; a screening for signs of depression, such
as withdrawal, anger or sad mood; assessment of the resident's
level of anxiety; and determining if the resident has a history of
psychiatric diagnosis that required in-patient treatment);
(F) Alzheimer's/dementia history;
(G) activities of daily living patterns (i.e., wakened to toilet
all or most nights, bathed in morning/night, shower or bath);
(H) involvement patterns and preferred activity pursuits (i.e.,
daily contact with relatives, friends, usually attended religious
services, involved in group activities, preferred activity
settings, general activity preferences);
(I) cognitive skills for daily decision-making (independent,
modified independence, moderately impaired, severely impaired);
(J) communication (ability to communicate with others,
communication devices);
(K) physical functioning (transfer status; ambulation status;
toilet use; personal hygiene; ability to dress, feed and groom
self);
(L) continence status;
(M) nutritional status (weight changes, nutritional problems or
approaches);
(N) oral/dental status;
(O) diagnoses;
(P) medications (administered, supervised, self-administers);
(Q) health conditions and possible medication side effects;
(R) special treatments and procedures;
(S) hospital admissions within the past six months or since last
assessment; and
(T) preventive health needs (i.e., blood pressure monitoring,
hearing-vision assessment).
| (2) The service plan must be approved
and signed |
| by the resident or a person responsible
for the resident's health care decisions. The facility must
provide care according to the service plan. The service plan
must be updated annually and upon a significant change in
condition, based upon an assessment of the resident. |
(3) For respite clients,
the facility may keep a
service
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| plan for six months from the date on
which it is developed. During that period, the facility may
admit the individual as frequently as needed. |
(4) Emergency admissions
must be assessed and a
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| service plan developed for them.
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*From: Texas Department of Aging and Disability
Services (DADS) Licensing Standards for Assisted Living Facilities
Subchapter A, §92.41
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