Resident health assessments – Ohio Admin. Code 3701-17-58

Residential care facilities must conduct initial health assessments and annual reassessments (or sooner if medically indicated) of prospective and current residents.  Such assessments must include documentation of the following:

• Medical diagnoses, if applicable;
• Prescription medications;
• Dietary requirements, including any food allergies;
• Weight;
• A functional assessment evaluating how the resident performs activities of daily living;
• Type of care or services, including the amount, frequency, and duration of skilled nursing care the resident needs;
• A determination by a physician as to whether the resident is capable of self-administering medications, and what assistance with self-administration is needed; 
• A determination by a physician as to whether the resident needs to have medications administered; and
• If skilled care is provided to the resident by staff members, a physician or nurse must determine: 
  • If the resident’s personal care needs have been affected by the skilled nursing care needs, and
  • If any changes are required in the manner personal care services are provided.

In addition to this information, initial health assessments must include documentation of the following:

• Psychological history, if applicable;
• Health history and physical, including cognitive functioning and sensory and physical impairments;
• Developmental diagnosis, if applicable; and
• Height.

If a resident’s needs exceed those which the facility is authorized to or can provide, or if the resident refuses needed services or fails to obtain services for which he is responsible, the facility must do the following:

• Meet with the resident and his sponsor (if applicable) to discuss his condition, the options available and their consequences, except in emergency situations;
• Seek intervention if the lack of needed services has resulted in a significant adverse change; 
• Provide or arrange for any needed services that the resident has not refused until the resident is discharged or transferred or the issue has been resolved, if an emergency does not exist;
• Transfer or discharge the resident in accordance with relevant provisions if the resident needs skilled nursing care or services beyond what the facility provides and the facility determines that such action is necessary on the basis of its meeting with the resident; and
• Retain a resident who refuses available services if this does not endanger the health, safety, and welfare of others and the resident does not require services beyond what the facility is authorized to provide.