Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 300 - SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE › Subpart S - PROVIDING SERVICES TO PERSONS WITH SERIOUS MENTAL ILLNESS › Section 300.4010 - Comprehensive Assessments for Residents with Serious Mental Illness Residing in Facilities Subject to Subpart S

Current through Register Vol. 48, No. 28, July 12, 2024
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.