Comprehensive Assessments for Residents with Serious Mental Illness Residing in Facilities Subject to Subpart S

Section 300 Section 300.4010  Comprehensive Assessments for Residents with Serious Mental Illness Residing in Facilities Subject to Subpart S a)         The facility shall establish an Interdisciplinary Team (IDT) for each resident.  The IDT is a group of persons that represents those professions, disciplines, or service areas that are relevant to identifying an individual's strengths and needs, and that designs a program to meet those needs.  The IDT includes, at a minimum, the resident; the resident's guardian; a Psychiatric Rehabilitation Services Coordinator (PRSC); the resident's primary service providers, including an RN or an LPN with responsibility for the medical needs of the individual; a psychiatrist; a social worker; an activity professional; and other appropriate professionals and care givers as determined by the resident's needs.  The resident or his or her guardian may also invite other individuals to meet with the IDT and participate in the process of identifying the resident's strengths and needs. b)         The IDT must identify the individual's needs by performing a comprehensive assessment as needed to supplement any preliminary evaluation conducted prior to admission to the facility.  The assessment shall be coordinated by a PRSC. c)         A comprehensive assessment must be completed by the IDT no later than 14 days after admission to the facility.  Reports from the pre-admission screening assessment or assessments conducted to meet other requirements may be used as part of the comprehensive assessment if the assessment reflects the current condition of the individual and was completed no more than 90 days prior to admission. The assessment shall include at least the following: 1)         A psychiatric evaluation completed by a  board certified or board eligible psychiatrist or, if countersigned by a board certified or board eligible psychiatrist, the evaluation may be completed by a person who is a certified psychiatric nurse, a nurse with a Bachelor of Science in Nursing (BSN) and two years of experience serving individuals with serious mental illness, or a registered nurse with five years of experience serving individuals with serious mental illness; a licensed clinical social worker; a physician; a licensed psychologist; or a licensed clinical professional counselor (LCPC) under the Professional Counselor and Clinical Professional Counselor Licensing Act [225 ILCS 107].  The psychiatric evaluation shall include: A)        Psychiatric history with present and previous psychiatric symptoms; B)        Comprehensive mental status examination, which includes: a statement of assets and deficits, a description of intellectual functioning, memory functioning, orientation, affect, suicidal/homicidal ideation, response to reality testing, and current attitudes and overt behaviors; and C)        Diagnostic formulation, problems, and diagnosis using the Diagnostic and Statistical Manual IV (DSM-IV), ensuring that information is recorded on as many of the five axes as appropriate. 2)         Psychosocial assessment performed by the Psychiatric Rehabilitation Services Director (PRSD), a social worker, an occupational therapist, an LCPC, or the PRSC if reviewed and countersigned by the PRSD.  The assessment shall cover the following points: A)        Identifying information (including resident's name, age, race, religion, date of admission; name of individuals giving information); B)        Reason for admission (including specific problems and how long the problems have existed in their current state; contributing factors to exacerbation of problems; most recent psychiatric treatment and effects; goals of nursing facility as articulated by referral source); C)        History of mental illness, treatment, and care (including age of onset; private and public hospital inpatient episodes; community mental health care; prior nursing facility placement; specific treatments and effects); D)        Personal history (including current marital status; marital history including name, occupation, and age of current and previous spouses; name, age, sex and occupation of children, if any; status of significant personal relationships with individuals (past and present); work history of individual including all known past professions and/or jobs); E)        Residential history (including, for the last two years, the types of housing (e.g., family, public housing, apartment, room, or community agency), relationship to other occupants, the total number of known moves; factors known to have contributed to past housing loss; the highest level of residential independence attained, approximate date and length; any patterns of persistent residential instability or homelessness); F)         Family history (including information regarding individual's parents and siblings; any significant family illnesses, especially psychiatric illnesses; history of traumatic or significant loss including where, when and effect on individual); and G)        Developmental history (including early life history, place of birth, where raised and by whom and with whom; school history; and history regarding friends, hobbies, interests, social activities and interactions). 3)         A skills assessment performed by a social worker, occupational therapist, or PRSD or PRSC with training in skills assessment.  The skills assessment shall include an evaluation of the resident's strengths, an assessment of the resident's levels of functioning, including but not limited to the following areas: A)        Self-maintenance (including basic activities of daily living such as hygiene, dressing, grooming, maintenance of personal space, care of belongings, diet and nutrition, and personal safety); B)        Social skills (including communication, peer group involvement, friendship, family interaction, male/female relationship, and conflict avoidance and resolution); C)        Community living skills (including use of telephone, transportation and community navigation, avoidance of common dangers, shopping, money management, homemaking (cleaning, laundry, meal preparation), and use of community resources); D)        Occupational skills (including basic academic skills; job seeking and retention skills; ability to initiate and schedule activities; promptness and regular attendance; ability to accept, understand and carry out instructions; ability to complete an application; and interview skills); E)        Symptom management skills (including symptom monitoring and coping strategies; stress identification and management; impulse control; medication management and self-medication capability; relapse prevention); and F)         Substance abuse management (including recovery, relapse prevention and harm reduction). 4)         Oral screening completed by a dentist or registered nurse. 5)         Discharge plan as required by Section 300.4060 of this Part. 6)         Other assessments recommended by the IDT or required elsewhere in this Part, or as ordered by the resident's physician or psychiatrist to clarify diagnoses or to identify concomitant motivational, cognitive, affective, or physical deficits that could have an impact on rehabilitation efforts and outcomes, as indicated by the individual's needs. 7)         A structured assessment of resident interests and expectations regarding psychiatric rehabilitation conducted by the PRSC or PRSD with each resident. The assessment shall include at a minimum: A)        Resident's identification of personal strengths, goals, needs, and resources; B)        Skill development and problem areas for which the resident expresses an interest in setting goals and participating in psychiatric rehabilitation programming; C)        Resident's beliefs and confidence regarding his/her capacity to develop increased skills and independence. d)         Based on the results of all assessments, the PRSD or PRSC shall develop a narrative statement for the IDT review that summarizes findings regarding the resident's strengths and limitations; indicates the resident's expressed interests, expectations, and apparent level of motivation for psychiatric rehabilitation; and prioritizes needs for skill development related to improved functioning and increased independence.  The IDT's assessment of overall rehabilitation focus for the resident will also be identified as one of the following levels: 1)         Basic skills training and supports with opportunities for community integration; 2)         Intensive skills training and supports with an increasing focus on community integration; or 3)         Advanced skills training and supports with active linkage and use of community services in preparation for expected discharge within six months.