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Kim Ioerger RN, Regional Director of OperationsSteve Kurtz RN, Regional Clinical Director

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Learn about the required pre-admission, post-admission, and ongoing nursing assessments

Identify the nursing documentation regulatory requirements and how to use them.

Describe a process to maintain and track the documentation and assessment timelines.

Ensure all nursing services are maintained and individualized for the resident.

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The Illinois Administrative Code Chapter 1, Section 146.245 requires the following nursing documentationStandardized InterviewInitial AssessmentComprehensive Resident Assessment – RAIResident Service PlanQuarterly EvaluationProgress Notes

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The Standardized Interview Assessment

The Standardized Interview Assessment is a review and an evaluation of the potential resident’s various abilities and skills

Self Administration of Medication Assessment

CCU (Case Coordination Unit) Pre-Screen includes OBRA 2536 which may prompt a mental health PAS screen and the DON (Determination of Need)-The screen’s purpose is to identify the resident’s nursing facility level of care need and that SLF placement is appropriate to meet the needs of the individual.

Sex Offender Check per IL Admin Code Chapter 1 Section 146.220

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Cognition Physical Ability Communication Ability Activities of Daily Living Medical Health History Mental Health History Behavior/Habits Immunization History Code Status/Advanced Directives

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Obtain a thorough medication review and current medication list

Assess ability to correctly: Identify medications State or write times of administration Open medication containers Safely store medications Measure appropriate amounts of medication Identify when to take or repeat PRNs Use medications in other forms or by other

routes ( ophthalmic, topical, injections, inhalants, or rectally)

Perform accu-checks or other needed testing.

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Typically score between 29 and 47 on the Determination of Need (DON)

Need assistance in one or more activities of daily living New screen not needed for a resident transferring from

another nursing facility with no break in service Out of state screen not acceptable Admitting SLF’s responsibility to obtain copy of screen or

contact health dept. for new screen Must be without a diagnosis of primary or secondary

developmental disability or serious and persistent mental illness

If the resident is moving from out of state, the CCU department must complete the assessment within 14 days of admission date to the SLF.

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Per IL Admin Code Chapter 1 Section 146.220 Must be without a diagnosis of primary or secondary developmental disability or serious and persistent mental illness

The developmental disability or mental illness must be determined by a qualified DHS screening agent.

If a mental illness is identified, the applicant may be referred for a Mental Health PAS screen to determine the severity and persistence of the mental illness.

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All applicants for admission will be prescreened through the following databases:

National Sex Offender Public Registry –www. Nsopr.gov

Illinois State Police Sex Offender Registration-www. Isp.state.il.us

Illinois Dept. of Corrections Registered Sex Offender database –www. Idoc.state.il.us

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Provide a letter to potential resident and/or contact person identifying the needed documents to be provided to the SLF, current medication list, insurance cards, Immunization history, POA or other advanced directive instruments, key contact information

Obtain a written consent for release of medical information Contact resident and/or family to schedule an appointment. Invite them

to a meal at the facility. This may help to alleviate anxiety and tension about the assessment process

Encourage the potential resident to come to the facility for the nursing assessment.

This is beneficial for the nurse’s time management and also allows the nurse to evaluate other skills including recall, problem solving, mobility, and general understanding or beliefs about the pending move and services offered. It also more likely assures that a person that has direct knowledge of the prospective residents current abilities, and may be able to describe any assistance and the nature of the support being provided ( med set-up, meals, shopping, etc.), will be in attendance.

Other arrangements may need to be made if the resident is unable to come to the facility

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If the resident lives out of state, the Standardized Assessment may be mailed to and completed by the resident and returned. Ensure that medical consent has been obtained to allow the nurse to contact the physician(s).

A telephone interview may also be conducted, and information verified by phone or fax. Also speaking with entities that are providing services including SNF, home health, other social support agencies or the PCP would be appropriate.

Assist the resident or family in obtaining a new PCP prior to admission to ensure continuity of medical management, with an initial office visit scheduled for just prior to or shortly after admission.

The Standardized Assessment can only be used if the resident is admitted within 90 days of completion.

Remind family members in attendance to avoid answering questions for the resident. Allowing the resident the time to answer the questions will help the nurse to better assess the resident.

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If a potential applicant is identified on any of the sex offender databases, the SLF must upon admission:Inform the Department and appropriate county and local

law enforcement offices of the identity of the identified offenders being admitted to the SLFNotify every SLF resident and resident’s guardian or

family in writing that such offenders are residents of the facilityDevelop a service plan in accordance with Section

146.245Ensure that the SLF has qualified staff to meet the needs

of the individual and required level of supervision at all times

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The Initial Assessment The Initial Resident Service Plan Self-Administration of Medication

Assessment Motorized wheelchair/scooter assessment TB Skin Test Screening

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Review of Standardized Interview Assessment Any new or additional information, geared

toward completion of RAI and Initial Service Plan

Must be completed within 24 hours after admission

Shall be completed by, or co-signed by a Licensed Practical Nurse or a Registered Nurse

Identify “hidden” topics, specialized needs, and resident preferences

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Must be completed within 24 hours after admission

Shall be completed by or co-signed by an LPN or RN

Identify needs, potential immediate problems, and strengths with current health care needs

Identify resident’s preferences with activities of daily living and care

The purpose of the Initial Service Plan is to communicate resident’s needs and level of assistance to direct care staff timely

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The Service Plan may be updated without the completion of an RAI and may be updated at any time

The Service Plan should address all services described in the Supportive Living Program rules that are being delivered by the SLF, including assistance with ADL’s, medication administration, and dietary needs

The Service Plan should include any outside services delivered by the SLF that are not required by the SLF program rules (meal reminders, escort services, etc.)

The Service Plan should address any services that a resident prefers or declines

The Service Plan should address any outside service entities such as PT/OT, Home Health Wound Care, Lab Service, etc.

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The Service Plan will be in the designated format approved by HFS. The format must have expected outcomes, approaches, frequency and duration of services.

Keep a perpetual calendar or tickler file that allows you to track and plan ahead with assessments and service plan dates. Pay particular attention to holidays or planned resident absences.

Assessments and Service Plan meetings do not have to take place in a conference room. It is often easier and more thorough to meet the resident in his/her apartment.

Address identified resident needs or impairments on the Service Plan. Examples: hearing impaired, bilateral hearing aids, applies per self with reminders.

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Review medication list and self-administration of medication assessment for any changes that may have occurred with meds, route, dosage, frequency, and ability to self administer

Document any changes that are identified Determine pharmacy provider and/or preference

for set up and delivery of medications The Self Administration of Medication

Assessment should be reviewed and completed as determined by facility policy

This is not a required assessment

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Set-up ( including planners, caddy, timed dispensers, blister cards, strip packets, unit dose powder when available, salad dressing cups with lids for liquids, insulin pen devices or pre-drawn syringes separated by dose or strength, medications with dosing parameter as an “add in” or separate blister, packet)

Verbal Cues ( staff education to task segmentation, recorded slide scale, speaking accu-check machines, clocks, watches, amplifiers)

Tactile Cues ( self adhesive Velcro dots, rubber bands, textured stickers) Adaptive Equipment ( adequate well lit work surface, lighted magnifiers,

hand towel, eye cups, extenders, long handled applicators, DYKEM, or shelf liner, pliers,

Visual Aids ( written or LARGE PRINT materials, icons, clip art, color coding )

Physical assistance ( sitting or lying down into reclined position for eye drops,

Resident teaching, demo and return demonstration of new or unfamiliar task.

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Identify resident’s ability to safely use device Ensures other residents, staff and visitors safety Lessens likelihood of facility property damage Not a mandatory required assessment. It is a

Quality and Safety tool to help provide guidance to the resident

The motorized device should be addressed on the Service Plan identifying the resident’s need and usage

May be completed by unlicensed staff, reviewed cosigned by nurse is recommended

Should be reviewed and/or updated as determined by policy

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Assessment should contain the following elements: Knowledge of the control mechanisms Ability to safely transfer and placement of body limbs onto the

motorized device Demonstrate the ability to: Operate device at designated speed with-in the community, at all

times Signal appropriately when approaching others and “blind”

corners drive to a set destination turn the device propel the device backwards maneuver through doorways, around furniture, on and off

elevator, and handicap door usage Identify if the resident requires additional training or practice

with the motorized device

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Use small orange cones used for bicycles Provide a “Rules of the Road” handout to the

resident which includes the expected facility usage rules and expected compliance (i.e. always on turtle speed, use of horn, limitations or other community expectations, etc.)

Review the findings of the assessment with the resident request that the resident sign the assessment and attach the Rules of the Road handout, place in resident record

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Establish parameters for re-evaluation: yearly, every 6 months, and/or as need if indicated

Suggest to the new driver to practice during low hallway traffic times, staff may offer to assist with practice sessions

Safety is the most important goal. Explain to the resident that even when the resident is driving safely, accidents may happen

Usage suggestions may include: stop and look, honk at every corner and before backing up, avoid usage in crowded settings. Staff should offer to assist residents to dining room tables or activity events

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Prospective resident shall have a tuberculin skin test in accordance with the Control of Tuberculosis Code (77 Ill.Adm.Code 696)

The test must be completed no more than 90 days prior to admission date to the SLF or commenced no more than 7 days after admission to the SLF and completed by the 21st day

Routine, periodic screening of residents should be determined by a risk assessment performed in cooperation with the local TB control authority annually

Signs and symptoms checklist should be completed on all new admissions and annually for past positive reactors.

Persons who are past positive reactors should be referred to the local TB authority and/or their physician for follow up which will include but may not be limited to a chest x-ray

A two step TB skin test should be conducted on admission and a one step annually thereafter. Documented past positive reactors should not be tested and should only complete the signs and symptoms checklist

A skin test and/ or chest radiograph does not replace a sign and symptom checklist

Immunization record should be kept on all residents

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Comprehensive Resident Assessment - RAI (Resident Assessment Instrument)

Resident Service Plan Quarterly Assessments Progress Notes Self-Administration Medication Assessment Motorized Device/Scooter Assessment

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Completion and RN signature within 14 days of admit date (Admit date = day 1) – no sooner than 7 days after admission

Annually within 366 days of RN signature Upon a significant change in the resident’s mental or

physical status If resident is in hospital during time of required RAI,

should be completed within 14 days of readmission If RAI is due during any other absence, should be

completed within 24 hours or return to the SLF RAI format may only be changed if computerized;

must contain all info found in IHFS form and approved by HFS staff

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Resident is the source for completion of this assessment. Family, significant others and staff are also valuable sources

Should be developed in conjunction with resident input

Should be reflective of current resident status and abilities, strengths and deficits

Utilize the RAI Manual distributed by HFS to clarify questions regarding specific coding scenarios, and specific look back periods

RN signature validates completion and accuracy of the information contained in the assessment

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Completion and RN signature within 7 days of completion of any RAI (RAI RN date = day 1)

Include Sex Offender information, if applicable Must be individualized to reflect resident’s needs and abilities. Should include coordination and inclusion of services delivered

by an outside entity Shall include a description of expected outcomes, approaches,

frequency and duration of services provided and whether licensed or unlicensed staff are providing the services

Should reflect information identified in RAI Shall include services recommended by the SLF but are refused

by the resident Reviewed quarterly and updated if necessary in conjunction with

quarterly evaluations, within 92 days of previous Service Plan (RN date = day 1)

Updated more often to reflect significant changes of condition or resident preferences

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Initial quarterly assessment completed within 92 days of initial RAI (RN date = day 1).

Subsequent quarterly assessments completed within 92 days of previous assessment and in conjunction with quarterly Service Plan.

Signed by an RN. Narrative assessment of resident’s overall

status/condition and identifies decline or improvement of health and behavior status.

Facilities my develop their own format but must include all information required in IHFS form.

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Narrative, episodic progress notes Shall be completed at least monthly to document

decline or improvement in resident status DOES NOT have to be completed if there is no

change in resident status Document notification of family and physician Document routine monitoring of resident

condition, such as monthly weight and vital signs Documents changes of medications and new

physician’s orders

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Spreadsheets Perpetual Calendars Tickler Files

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