§ 2800.224. Initial assessment and preliminary support plan.

 (a)  Initial assessment.

   (1)  The administrator, administrator designee, or LPN, under the supervision of an RN, or an RN shall complete the initial assessment.

   (2)  An individual shall have a written initial assessment that is documented on the Department’s assessment form within 30 days prior to admission unless one of the conditions contained in paragraph (3) apply.

   (3)  A resident shall have a written initial assessment that is documented on the Department’s assessment form within 15 days after admission if one of the following conditions applies:

     (i)   The resident is being admitted directly to the residence from an acute care hospital.

     (ii)   The resident is being admitted to escape from an abusive situation.

     (iii)   The resident has no alternative living arrangement.

   (4)  A residence may use its own assessment form if it includes the same information as the Department’s assessment form.

   (5)  The written initial assessment must, at a minimum include the following:

     (i)   The individual’s need for assistance with ADLs and IADLs.

     (ii)   The mobility needs of the individual.

     (iii)   The ability of the individual to self-administer medication.

     (iv)   The individual’s medical history, medical conditions, and current medical status and how they impact or interact with the individual’s service needs.

     (v)   The individual’s need for supplemental health care services.

     (vi)   The individual’s need for special diet or meal requirements.

     (vii)   The individual’s ability to safely operate key-locking devices.

     (viii)   The individual’s ability to evacuate from the residence.

 (b)  An initial assessment will not be required to commence supplemental health care services to a resident of a residence under any of the following circumstances:

   (1)  If the resident was not receiving the services at the time of the resident’s admission.

   (2)  To transfer a resident from a portion of a residence that does not provide supplemental health care services to a portion of the residence that provides such service.

   (3)  To transfer a resident from a personal care home to a residence licensed by the same operator.

 (c)  Preliminary support plan.

   (1)  An individual requiring services shall have a written preliminary support plan developed within 30 days prior to admission to the residence unless one of the conditions contained in paragraph (2) applies.

   (2)  A resident requiring services shall have a written preliminary support plan developed within 15 days after admission if one of the following conditions applies:

     (i)   The resident is being admitted directly to the residence from an acute care hospital.

     (ii)   The resident is being admitted to escape from an abusive situation.

     (iii)   Any other situation where the resident has no alternative living arrangement.

   (3)  The written preliminary support plan must document the dietary, medical, dental, vision, hearing, mental health or other behavioral care services that will be made available to the individual, or referrals for the individual to outside services if the individual’s physician, physician’s assistant or certified registered nurse practitioner, determine the necessity of these services. This requirement does not require a residence to pay for the cost of these medical and behavioral care services. The preliminary support plan must document the assisted living services and supplemental health care services, if applicable, that will be provided to the individual.

   (4)  The preliminary support plan shall be documented on the Department’s support plan form.

   (5)  A residence may use its own support plan form it if includes the same information as the Department’s support plan form. An LPN, under the supervision of an RN, or an RN shall review and approve the preliminary support plan.

   (6)  An individual’s preliminary support plan must document the ability of the individual to self-administer medications or the need for medication reminders or medication administration and the ability of the resident to safely operate key-locking devices.

   (7)  An individual shall be encouraged to participate in the development of the preliminary support plan. An individual may include a designated person or family member in making decisions about services.

   (8)  Individuals who participate in the development of the preliminary support plan shall sign and date the preliminary support plan.

   (9)  If an individual or designated person is unable or chooses not to sign the preliminary support plan, a notation of inability or refusal to sign shall be documented.

   (10)  The residence shall give a copy of the preliminary support plan to the resident and the resident’s designated person.

Cross References

   This section cited in 55 Pa. Code §  2800.22 (relating to application and admission).



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