University of Minnesota Long Term Care Resource Center
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Resident Assessment

 

Description of Federal Requirements
Comparison of State Requirements
Table Comparing States
Complete Transcript of State Requirements on Resident Assessment (PDF)

 

Federal Regulations & Related F-tags for 483.20 Applicable Federal Regulation
(a) Admission Orders | F271
(b - v) Comprehensive assessments | F272 - F275
(c) Quality review assessment | F276
(1-2) Comprehensive Care Plans | F279 - F280
(d) Use | F286
(e) Coordination & Preadmission Screening | F285
(f) Automated data processing requirements | F287
(c) Accuracy of assessment | F278
(h) Coordination | F278
(i) Certification | F278
(j) Penalty for falsification | F278
(3)-(ii) Comprehensive care plans | F281 - F282
(l) Discharge Summary | F283 - F284
(m) Preadmission screening for mentally Ill individuals and individuals with mental retardation | F285
  • 483.20 Resident Assessment
  • 483.10 Resident Rights
  • 483.25 Quality of Care
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    Description of Federal Requirements    (TOP)    (NEXT)

    The facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each residents’ functional capacity.

    The regulations in this section range from admission orders to discharge summaries. At admission, the facility must have physician orders for the resident’s immediate care. Within 14 calendar days after admission a facility must make a comprehensive assessment of a resident’s needs using the resident assessment instrument (RAI) specified by the State. The assessment must include at least the following: identification and demographic information; customary routine; cognitive patterns; communication; vision; mood and behavior patterns; psychosocial well-being; physical functioning and structural problems; continence; disease diagnoses and health conditions; dental and nutritional status; skin condition; activity pursuit; medications; special treatments and procedures; discharge potential; documentation of summary information regarding the additional assessment performed through the resident assessment protocols and documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. After the initial assessment, re-assessment is required within 14 calendar days after the facility determines, or should have determined, that there has been a significant change in the resident’s physical or mental condition or not less often than once every 12 months. Quarterly review assessment using the quarterly review instrument specified by the State and approved by CMS is required not less frequently than once every 3 months. All resident assessments completed within the previous 15 months must be maintain in the resident’s active record and the results must be used to develop, review, and revise the resident’s comprehensive care plan. A facility must coordinate assessments with the preadmission screening and resident review program under Medicaid to the maximum extent practicable to avoid duplicative testing and effort. Within 7 days after a facility completes a resident’s assessment they must encode the following information for each resident in the facility: admission assessment; annual assessment updates; significant change in status assessments; quarterly review assessments;; a subset of items upon a resident’s transfer, reentry, discharge, and death; background information if there is no admission assessment. This data must be capable of being transmitted to the State within 7 days after a facility completes a resident’s assessment in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. A facility must electronically transmit at least monthly, encoded, accurate, complete MDS data to the State for all assessments conducted during the previous month. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS. A facility may not release information that is resident identifiable to the public but may release information to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. The assessment must accurately reflect the resident’s status, be conducted or coordinated by a registered nurse who must sign and certify that the assessment is completed. Each person who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. A person who willfully and knowingly falsifies material or statements in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment. If a person causes another individual to certify a material and false statement in a resident assessment is subject to a penalty of not more than $5,000 for each assessment. Clinical disagreement does not constitute a material and false statement.

    The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the following: services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and psychosocial well-being; any services that would otherwise be required under 483.25 (Quality of Care) but are not provided due to the resident’s exercise of rights under 483.10 (Resident’s Rights) including the right to refuse treatment under 483.10(b)(4) (Right to Refuse Treatment). A comprehensive care plan must be developed within 7 days after completion of the comprehensive assessment; be prepared by an interdisciplinary team that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident’s needs and if possible, the participation of the resident, the resident’s family or legal representation. The care plan must be periodically reviewed and revised by a team of qualified persons after each assessment and services must be provided or arranged by the facility that meet professional standards of quality and be provided by qualified persons in accordance with each resident’s written plan of care.

    When the facility anticipates discharging a resident a discharge summary that includes: a recapitulation of the resident’s stay; a final summary of the resident’s status; a post-discharge plan of care that is developed with the participation of the resident and his or her family, which will assist the resident to adjust to his or her new living environment.

    After January 1, 1989, preadmission screening for mentally ill individuals and individuals with mental retardation is required unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, that, because of the physical and mental condition of the person, the person requires the level of services provided by a nursing facility; and if the person requires such level of services, whether the person requires specialized services or if a developmental disability authority has determined prior to admission that, because of the physical and mental condition of the person, the person requires the level of services provided by a nursing facility and if the person requires such level of services, whether the person requires specialized services for mental retardation. 

     Previously, monthly transmittal requirements required a facility to electronically transmit, at least monthly, encoded, accurate, complete MDS data to the state. In 2009, Transmittal requirements were changed to: “within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System….”

    Comparison of State Requirements    (TOP)    (NEXT)

    NOTE:  The examples below may not list all States with similar language; always check your state for specifics

    These Federal regulations are specific and most states follow them, if not word to word, then to the intent of the Federal rules. In Alabama the facility must make a comprehensive assessment of a resident’s needs which for Medicare/Medicaid certified facilities only is based on a uniform data set specified by the Secretary and uses an instrument that is specified by the State and approved by the Secretary. Montana has very specific rules for preadmission screening for persons with mental retardation or a related condition. Level I screening means a review of a nursing facility applicant to identify whether the applicant has a primary or secondary diagnosis or indications of mental retardation or of mental illness and level II screening means an assessment applied to persons identified as having a primary or secondary diagnosis of mental retardation or mental illness which determines whether the person as a nursing facility applicant has need for the level of services provided by the nursing facility or by another type of facility and, if so, whether the individual requires active treatment.

    Alabama may require the use of independent assessors if the State determines, under a survey or otherwise, that there has been a knowing and willful certification of false statements. For a period specified by the State, the State may required that resident assessments be conducted and certified by persons who are independent of the facility and who are approved by the State.

    In Alabama, the comprehensive assessment must include at least the following information: medically defined conditions and prior medical history; medical status measurement; physical and mental functional status; sensory and physical impairments; nutritional status and requirements; special treatments or procedures; mental and psychosocial status; discharge potential; dental condition; activities potential; rehabilitation potential; cognitive status and drug therapy.

    Arkansas addresses therapeutic diets requiring a system of written communications between dietetic service and nursing services. Nursing services should send a written patient diet list monthly and diet change slips as diets are changed by the physician. Therapeutic diets shall be served only to those patients for whom there is a physician’s or dentist’s written order.

    California has extensive regulations for resident assessment and planning of patient care. Guidelines require the development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished, and the professional discipline responsible for each element of care. Objective shall be measurable and time-limited. The attending physician must be promptly notified in the following situations: the admission of a patient; any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient; an unusual occurrence involving a patient; a change in weight of five pounds or more within a 30-day period unless a different stipulation has been stated in writing by the patient’s physician; any untoward response or reaction by a patient to a medication or treatment; any error in the administration of a medication or treatment to a patient which is life threatening and presents a risk to the patient; the facility’s inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present a risk to the health, safety or security of the patient. Content of health records include: admission record; current report of physical examination, and evidence of tuberculosis screening; current diagnoses; physician orders, including drugs, treatment and diet orders, progress notes, signed and dated on each visit (physician’s orders shall be correctly recapitulated); and nurses’ notes which shall be signed and dated. Notes shall include records made by nurses assistants, after proper instruction, which shall include: care and treatment of the patient; narrative notes of observation of how the patient looks, feels, eats, drinks, reacts, interacts and the degree of dependency and motivation toward improved health; notification to the licensed nurse of changes in patient’s condition; meaningful and informative nurses’ progress notes written by licensed nurses as often as the patient’s condition warrants. However weekly nurses’ progress notes shall be written by licensed nurses on each patient and shall be specific to the patient’s needs, the patient care plan and the patient’s response to care and treatments. Records of type of restraint and time of application and removal are required. The time of application and removal shall not be required for postural supports used for the support and protection of the patient.

    In Colorado, the nursing care plan shall meet each residents’ unique needs, problems, and strengths by identifying resident strengths, needs, and problems; specifying care interventions to capitalize on the strengths and meet those needs or problems; and defining the frequency of each intervention. Social services care planning specifies that the social services staff assess social services needs within one week of admission and develop a social services care plan to meet each resident’s needs. Activities care planning specifies that the activities staff shall assess activities needs within one week of admission and shall develop an activities care plan to meet each resident’s needs. Nutritional care planning requires the Dietary supervisor or consultants to prepare an initial nutritional history and assessment for each resident within 2 weeks of admission that includes special needs, likes and dislikes, nutritional status, and need for adaptive cutlery and dishes and then develop a plan of care to meet these needs. In the even the facility elects to utilize paid feeding assistants or feeding assistant volunteers, the interdisciplinary team shall evaluate each resident regarding the suitability of the resident to be fed and hydrated by a feeding assistant. Interdisciplinary care planning team shall consist of representatives of resident services inside and outside the facility, as appropriate, including at least nursing, social services, activities, and dietetic staff. Other persons, such as medical, pharmacy, and special therapies, shall be included as appropriate. Residents and their representatives shall be invited to participate in care planning. Refusal to participate shall be documented. Maryland requires the facility to establish a skin care record documenting skin, hair, and nail condition on admission. If any abnormal conditions exist, the staff shall document progression of the condition or conditions weekly until the condition or conditions have healed. At any time that a skin condition persists for more than 7 days, staff shall add the condition to the skin record. In Massachusetts, the nursing care plan shall be an organized, written daily plan of care for each patient. It shall include: diagnoses, significant conditions or impairments, medication, treatments, special orders, diet, safety measure, mental condition, bathing and grooming schedules, ADLs, the kind and amount of assistance needed, long-term and short term goals, planned patient teaching programs, encouragement of patient’s interests and desirable activities. It shall indicate what nursing care is needed, how it can best be accomplished, and what methods and approaches are most successful. This information shall be summarized on a cardex and be available for use by all personnel involved in patient care. In Minnesota nursing assistants may document in the nursing notes if allowed by nursing home policy. In Oregon the care plan shall provide for and promote personal choice and independence of the resident.  In Texas, a comprehensive care plan may include a palliative plan of care. This plan may be developed only at the request of the resident, surrogate decision maker or legal representative for residents with terminal conditions, end stage diseases or other conditions for which curative medical interventions are not appropriate. The plan must have goals that focus on maintaining a safe, comfortable and supportive environment in providing care to a resident at the end of life. In Washington, the facility must respect the resident’s right to decide plan of care goals and treatment choices, including acceptance or refusal of plan of care recommendations; include in the interdisciplinary plan of care process: staff members requested by the resident; and direct care staff who work most closely with the resident; and respect the resident’s wishes regarding which individuals, if any, the resident wants to take part in resident plan of care functions. Wisconsin has procedures for recuperative care plans 

    Of all the states, Connecticut has the most detailed regulations for resident assessment, especially in section on patient examination. There is a detailed list of tests and procedures required within 30 days after admission. Physician visits are regulated as to each patient in nursing home shall be examined by his/her personal physician at least once every 30 days for the first 90 days after admission. After 90 days, alternative schedules for visits may be set if the physician determines and so justifies in the medical record that the patient’s condition does not necessitate visits at 30 day intervals. At no time may the alternative schedule exceed 60 days between visits. Annually, each patient shall receive a comprehensive medical examination, at which time the attending physician shall update the diagnosis and revise the individual’s overall treatment plan in accordance with such diagnosis.

    Hawaii address the medical record system by requiring that there shall be available sufficient, appropriately qualified staff and necessary supporting personnel to facilitate the accurate processing, checking, indexing, filing, and prompt retrieval of records and record data. If the employee who supervised medical records is not a registered records administrator, or accredited record technician, there shall be regularly scheduled visits by a consultant so qualified who shall provide report to the administrator.

    In Illinois authentication shall include the initials of the signer’s credentials. If the electronic signature system will not allow for the credential initials, the facility shall have a means of identifying the signer’s credentials. The facility shall have a written policy on electronic medical records that addresses persons authorized to make entries, confidentiality, monitoring of record entries, and preservation of information. The facility shall develop a policy to assure that only authorized uses make entries into medical records and that users identify the date and author of every entry in the medical records. The policy should allow written signatures, written initials supported by a signature log, or electronic signatures with assigned identifiers, as authentication by the author that the entry made is complete, accurate and final. The facility shall develop a policy to periodically monitor the use of identifiers and take corrective action as needed. The facility shall maintain a master list of authorized users past and present and maintain a computerized log of all entries. The logs shall include the date and time of access and the user ID under which access occurred. A user may terminate authorization for use of electronic or computer-generated signature upon written notice to the individual responsible for medical records or other person designated by the facility’s policy. All physicians’ orders, plans of treatment, Medicare or Medicaid certification, recertification statements, and similar documents shall have the authentication of the physician. The use of a physician’s rubber stamp signature, with or without initials, is not acceptable.  In Louisiana, If electronic signatures are used, the nursing home shall develop a procedure to assure the confidentiality of each electronic signature and to prohibit the improper or unauthorized use of any computer generated signature. If a facsimile communications system (FAX) is used, the nursing home shall take precautions when the thermal paper is used to ensure that a legible copy is retained as long as the clinical record is retained. Maine requires that all recording is done in the facility. In South Carolina the use of rubber stamp signatures is acceptable under the following strict conditions: (a) the physician whose signature the rubber stamp represents is the only one who uses it; (b) the physician places in the administrative office of the facility a signed statement to the effect that he is the only one who has the rubber stamp and is the only one who will use it. However, it must be emphasized that use of rubber stamp signatures is not permissible on orders for drugs listed as “Controlled Substances”.

    In Indiana, If a death occurs, information concerning the resident’s death shall include the following: notification of the physician, family, responsible person, and legal representative; the disposition of the body, personal possessions, and medications; a complete and accurate notation of the resident’s condition and most recent vital signs and symptoms preceding death.

    Table Comparing States    (TOP)

    Note: If the States in this table are not hyper-linked, their provisions do not appear to address the topic, and therefore, do not alter the Federal Regulatory scope.  The Table summarizes content on Resident Assessment by State (with a link to each State's specific language).  Link to a downloadable PDF document containing all State requirements on Resident Assessment.

    483.20 Resident Assessment

    State Goes beyond Federal Regulations? Subjects Addressed: How State Differs From or Expands On Federal Regulations
    Alabama Yes Extensive regulations that include: resident assessment; admission orders; comprehensive assessments; comprehensive care plan; discharge summary; pre-admission screening for mental illness to include capability to perform daily life functions and significant impairments in a functional capacity. Comprehensive assessment must include: medically defined conditions and prior medical history; medical status measurement; physical and mental functional status; sensory and physical impairments; nutritional status and requirements; special treatments or procedures; mental and psychosocial statues; discharge potential; dental condition; activities potential; rehabilitation potential; cognitive status and drug therapy.
    Alaska Yes Rules that specify a RN in conjunction with an interdisciplinary team shall prepare assessment using instrument approved by department. Plan must reflect analysis of patient problems, treatment, medication and benefits.
    Arizona Yes Resident assessment rules included in resident rights section, content of assessment, care plan, admission and transfer or discharge summary.
    Arkansas Yes Therapeutic diets, physician or dentist verbal or telephone orders, admission, transfer and discharge policies, assessments for special care units,
    California Yes Lists nursing services that includes: planning of care; identification of needs based on assessment; development of patient care plan; reviewing evaluating and updating care plan; implementation physician notification; special treatment programs; content of health records,
    Colorado Yes Clearly defined assessment regulations that include: initial assessment within 24 hours of admission which will form basis of preliminary care plan to be done within 7 days of admission; nursing care plan which s an individualized tool for carrying out preventive, therapeutic and rehabilitative nursing care; a social service care plan; activities care plan; nutritional care plan including suitability of use of feeding assistant for this resident; interdisciplinary care plan; administrator screening responsibilities; social service and secure units requirements.
    Connecticut Yes Comprehensive rules that include: medical records; medical & professional services; comprehensive examination; list of test and procedures to be performed within 30 days of admission;; physician visits; and discharge planning.
    Delaware Yes Personal and medical records to include documented observations; specialized services; orders for restraints; medications; physician orders and progress notes; nursing notes; medication sheets; discharge record; and availability of records; content of comprehensive assessment and food service.
    District of Columbia Yes Comprehensive medical exam documented in medical record.
    Florida Yes Focuses on deficiencies for failure of facility to maintain or reach his or her highest practical physical, mental, or psychosocial well-being, as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services. Resident assessment and care plan contents.
    Georgia Yes Each home shall maintain a complete medical record on each patient containing sufficient information to validate the diagnosis and to establish the basis upon which treatment is given. All active medical records shall be maintained at the nurses' station.
    Hawaii Yes Section on medical record system that must contain the following information: identifying information; name & address of next of kin or legal guardian; personal data including identifying marks; orison for admission; language spoken or understood; information relevant to religious affiliation; admission diagnosis. Records during stay shall include: appropriate authorizations for medical procedures; records of all periods of restraints with justification and authorization for each; copies of initial and periodic exams; regular review for care planning; entries describing treatments and written evidence of the reason a patient is transferred to another facility or discharged; dietetic services; physicians responsibilities.
    Idaho Yes Rules that include responsible staff for accurate maintenance of medical records and rules for individual medical record including that all records shall be either typewritten or recorded legibly in ink; nursing services; assessment requirements.
    Illinois Yes Extensive resident record requirements including: detailed section on electronic medical records policy; authentication procedures for preparer; content of medical records; retention and transfer of resident records (minimum of 5 years); other resident record requirements including the facility must document in the resident's record any medical inadvisability regarding married residents residing in the same room; staff responsibility for medical records; and retention of facility records. Determination of need screening and request for resident criminal history record information; identified offenders; assessment and care planning and ability centered care for Alzheimer’s special care units.
    Indiana Yes Clinical records on each resident must be as follows: complete; accurately documented; readily accessible; and systematically organized. Each facility shall have a well-defined policy that ensures the staff has sufficient progress information to meet the residents' needs. If a death occurs, information concerning the resident's death shall include: notification of the physician, family, responsible person, and legal representative; the disposition of the body, personal possessions and medications; a complete and accurate notation of the resident's condition and most recent vital signs and symptoms preceding death; preadmission screening; admission orders; comprehensive assessment; care planning; discharge summary;
    Iowa Yes Brief sections on individual health care plans that shall be based on the nature of the illness or disability, treatment, and care prescribed; duties of health service supervisor; physical therapy services and responsibilities of consultant dietitian.
    Kansas Yes Resident assessment must be conducted at the time of admission and periodically thereafter, a comprehensive assessment of a resident's needs on an instrument approved by the secretary of health and environment. Closely follows federal regulations. Special care section requirements.
    Kentucky Yes Includes required information for comprehensive assessment and care plan and coordination requirements. 
    Louisiana Yes After initial assessment of the resident's Needs/problems a care plan shall be completed within 21 days of admission. If electronic signatures are used, the facility shall develop a procedure to assure the confidentiality of each electron signature and to prohibit the improper or unauthorized use of any computer generated signature. If a FAX is used, the facility shall take precautions when thermal paper is used to ensure that a legible copy is retained as long as the clinical record is retained.
    Maine Yes Regulations include: clinical records; retention of records; active clinical records; purging of the active clinical records; miscellaneous records; inactive clinical records; readmissions; transfers and discharges; incident and accident records; individual administrative records; confidentiality; and access. Pre-admission screening for mental illness and mental retardation.
    Maryland Yes Clinical records procedures include: records for all patients; contents of records; staffing designee; consultation requirements; completion of records and centralization of reports; retention and preservation of re cords; current records; closed or inactive records. Rules for care planning include interdisciplinary team; time of assessments; 7 day advance notice of care planning conference; organization of care plan; availability of care plan; and special skin record procedure. Resident care management system.
    Massachusetts Yes Care plan shall be an organized written daily plan of care for each patient and shall indicate what nursing care is needed, how it can best be accomplished, and what methods and approaches are most successful. This information shall be summarized on a cardex and be available for use by all personnel involved in patient care. Care plan review rules.
    Michigan Yes A health facility shall comply with the medical records access act Sec. 20170. Patient care planning requirements and discharge planning.
    Minnesota Yes Comprehensive and well organized set of regulations that include: 1. assessment; information gathered; frequency; review of assessment;  2. development of comprehensive plan of care; contents of plan of care; use;  revisions procedures; 3. clinical record contents; physician and professional services; nursing services; dietary and food services; resident personal funds account; activities; social services; 4. clinical record; unit record; form of entries and authentication; classification systems; admission information.
    Mississippi Yes Brief regulations requiring that a medical record shall be maintained in accordance with accepted professional standards and practices on all residents admitted to the facility. A resident index, including the resident's full name and birthday, shall be maintained. Requirements for admission and assessment and individual care plans for Dementia special care units.
    Missouri Yes Assessments and individual service plans. Prior to admitting or continuing to care for a resident diagnosed with Alzheimer's disease or other dementia the facility must determine if they can meet the needs of the resident. The facility shall document the de decisions regarding admission or continued placement in the facility through written verification. If the facility admits or continues to care for a resident, a MDS assessment shall be completed on an MDS form provided by the Division of Aging to assess the needs of each resident who is mentally incapable of negotiating a "pathway to safety". Resident Assessment Instrument to be used; frequency of assessments; evaluation and assessment measures for Title XIX recipients and applicants in LTC facilities.
    Montana Yes Rules pertain to "nursing facility" category which includes hospitals, treatment centers, hospices and other health related facilities. Difficult to separate rules pertaining to nursing homes. Rules include many definitions. Preadmission screening for persons with mental retardation or related condition includes Level I which means review of a nursing facility applicant to identify whether applicant has a primary or secondary diagnosis or indications of mental retardation or mental illness and level II screening which means an assessment applied to persons identified as having a primary or secondary diagnosis of mental retardation or mental illness which determines whether the person as a nursing facility applicant has need for the level of services provided by the nursing facility or by another type of facility and, if so, whether the individual requires active treatment. MDS submission requirements and influence on reimbursement included.
    Nebraska Yes Record keeping requirements include clinical records; clinical record safeguards; records are subject to inspection by authorized representative of the department; record retention and preservation; other resident records; resident possession inventory; and chronological resident register. Content; frequency; review of assessments; care plans; interdisciplinary evaluation of resident needs; review and revision; discharge summary;
    Nevada Yes A facility shall conduct a comprehensive assessment of the needs of each patient in the facility using the assessment instrument specified by the Bureau. Regulations follow Federal regulations. Discharge summary
    New Hampshire Yes Resident records for each resident shall be written and current, and kept of file in the facility until the resident is discharge. Although the facility shall retain and maintain the resident record, the medical information in the resident record is the property of the resident who has the right to receive a copy of all information contained in this record. Required services to include RAI and MDS.
    New Jersey Yes Includes regulations for mandatory resident assessment and care plans; reassessments; advisory resident assessment and care plans; mandatory communication that requires that staff shall always communicate with residents and families in a respectful way and shall introduce and identify themselves to resident as required and necessary.
    New Mexico Yes Duties relating to medical records shall be completed in a timely manner and include: the medical records shall be available and accessible; shall be systematically organized; maintained on unit; master resident index required; maintenance; retention and destruction; records documentation; medical records content; identification and summary sheet; physician's documentation; nursing service documentation; social services records; activities records; rehabilitative services; dietary assessment; dental services; diagnostic services; plan of care; authorization or consent; and discharge or transfer information.
    New York Yes Rules on clinical records that they completed with accepted professional standards and practices. Content of resident assessment;  review of assessment; discharge summary; admission policies and practices.
    North Carolina Yes Patient assessment and care planning are brief and follow Federal requirements.
    North Dakota Yes The facility shall complete and maintain an up-to-date comprehensive resident assessment for each resident by using the resident assessment instrument, the utilization guidelines, the minimum data set of core elements and common definitions, and the resident assessment protocol summary with triggers as specified by the department and approved by HCFA and published in the state operations manual. Governing body shall develop and implement written care policies.
    Ohio Yes Each nursing home, in accordance with this rule, shall require written initial and periodic assessments of all residents. The different components of the assessment may be performed by different licensed health care professionals, consistent with the type of information required and the professional's scope of practice, as defined by applicable law, and shall be based on personal observation and judgment. Includes section requirements for residents with significant Mantoux tests. Resident assessment: tuberculosis testing; admission planning; comprehensive assessment requirements; use of instrument.
    Oklahoma Yes A resident assessment and an individual care plan shall be completed and implemented for each resident. The care plan shall indicate the resident's current status and accurately identify the resident's needs. Assessment requirements including current pain measured at its least and greatest levels; aggravating and relieving factors; and treatment.
    Oregon Yes The comprehensive assessment shall be on a form specified by the Division. Regulations for care plan preparation and implementation include: the plan shall provide for and promote personal choice and independence of the resident. It shall be written in ink and made a part of the resident's clinical record. Client preadmission screening, resident review; purpose of private admission assessment is to ensure that non-Medicaid eligible persons applying to a Medicaid certified facility receive information regarding appropriate service alternatives. Assessment process and qualifications for personnel performing admission assessments.
    Pennsylvania Yes The facility shall designate an individual to be responsible for the coordination and implementation of a written resident care plan. Clinical records shall be available to, but not be limited to, representative of the Department of Aging Ombudsman Program.
    Rhode Island Yes Follows Federal regulations. The administrator shall have ultimate responsibility for the maintenance of medical records; such responsibility may be delegated in writing to a staff member.
    South Carolina Yes Medical records Rubber Stamp Signature. The use of rubber stamp signatures is acceptable under the following strict conditions: the physician whose signature the rubber stamp represents is the only one who uses it; and the physical places in the administrative offices of the facility a signed stamen to the effect that he is the only one who has the rubber stamp and is the only one who will use it. However, it must be emphasized that use of rubber stamp signatures is not permissible on orders for drugs listed as "Controlled Substances".
    South Dakota Yes The nursing service of a health care facility must provide safe and effective care from the day of admission through the ongoing development and implementation of written are plans for each patient or resident. Resident assessment requirements and reviews.
    Tennessee Yes Tennessee regulations do not contain specific information on resident assessment.
    Texas Yes Lengthy regulations that follow Federal regulation and include civil monetary penalties and provision that comprehensive care plan may include a palliative plan of care. Requirements for requiring nursing home residents who are considering a transition to a community-based care to receive mental health and retardation screening and plan of care.
    Utah Yes Simply definitions of health services supervisor and role in written health care plan and patient care plan definition. Requirements for small care facilities.
    Vermont Yes Follows and expands on Federal regulations. Includes provision that a post-discharge plan of care be developed with the participation of the resident and his or her family, which will assist the resident to adjust to this or her new living environment.
    Virginia Yes Generic rules for development resident assessment and comprehensive plan of care.
    Washington Yes Extensive rules for resident assessment and plan of care. The comprehensive plan of care must: describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and describe any services that would otherwise be required, but are not provided due to the resident's exercise of rights, including the right to refuse treatment; respect the resident's wishes regarding which individuals, if any, the resident wants to take part in resident plan of care function; include in the interdisciplinary plan of care process staff members requested by the resident. Utilization review.
    West Virginia Yes Includes rules that follow Federal guidelines including civil money penalty for falsification and use of independent assessors. Comprehensive care plan development policies.
    Wisconsin Yes Resident care planning shall include realistic goals, with specific time limits for attainment and methods for delivering needed care and indication of which professional disciplines are responsible for delivering the care. Rules for care planning procedures for recuperative care. Procedures for admission evaluation.
    Wyoming Yes Wyoming regulations do not contain specific content for Resident Assessment.

    Complete Transcript of State Requirements on Resident Assessment (PDF)    (TOP)