410 IAC 16.2-5-2
410 IAC 16.2-5-2 Evaluation
Cite as Ind. Admin. Code tit. 410, r. 16.2-5-2
Sec. 2. (a) An evaluation of the individual needs of each resident shall be initiated prior to admission and shall be updated at least
semiannually and upon a known substantial change in the resident's condition, or more often at the resident's or facility's request. A licensed nurse
shall evaluate the nursing needs of the resident.
(b) The preadmission evaluation (interview) shall provide the baseline information for the initial evaluation. Subsequent evaluations shall
compare the resident's current status to his or her status on admission and shall be used to assure that the care the resident requires is within the range
of personal care and supervision provided by a residential care facility.
(c) The scope and content of the evaluation shall be delineated in the facility policy manual, but at a minimum the needs assessment shall
include an evaluation of the following:
(1) The resident's physical, cognitive, and mental status.
(2) The resident's independence in the activities of daily living.
(3) The resident's weight taken on admission and semiannually thereafter.
(4) If applicable, the resident's ability to self-administer medications.
(d) The evaluation shall be documented in writing and kept in the facility.
(e) Following completion of an evaluation, the facility, using appropriately trained staff members, shall identify and document the services
to be provided by the facility, as follows:
(1) The services offered to the individual resident shall be appropriate to the:
(A) scope;
(B) frequency;
(C) need; and
(D) preference;
of the resident.
(2) The services offered shall be reviewed and revised as appropriate and discussed by the resident and facility as needs or desires
change. Either the facility or the resident may request a service plan review.
(3) The agreed upon service plan shall be signed and dated by the resident, and a copy of the service plan shall be given to the resident
upon request.
(4) No identification and documentation of services provided is needed if evaluations subsequent to the initial evaluation indicate no
need for a change in services.
(5) If administration of medications or the provision of residential nursing services, or both, is needed, a licensed nurse shall be
involved in identification and documentation of the services to be provided.
(f) For purposes of IC 16-28-5-1, a breach of:
(1) subsection (a), (b), or (e) is a deficiency; and
(2) subsection (c) or (d) is a noncompliance.