Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 295 - ASSISTED LIVING AND SHARED HOUSING ESTABLISHMENT CODE › Subpart I - PHYSICAL PLANT AND ENVIRONMENTAL REQUIREMENTS › Appendix A - Physician's Assessment Form

Current through Register Vol. 48, No. 28, July 12, 2024
Resident Name: ____________________ Resident Representative,
				  If any: ____________
Birth Date: ________________________ Telephone:
				  ____________________________
Telephone: ________________________ Street Address:
				  ________________________
Street Address _____________________ City/State/Zip:
				  _________________________
City/State/Zip ______________________
______________________________________________________________________
______________________________________________________________________
Other Emergency Contact Person:
				  ___________________________________________
Complete Address:
				  _______________________________________________________
Telephone Number:
				  _______________________________________________________
______________________________________________________________________
______________________________________________________________________
Purpose of Assessment:
Prior to
				  AdmissionAnnualSignificant
				  Change in Condition
ESTABLISHMENT
Name:
				  ________________________________________________________________
Street Address:
				  _________________________________________________________
City/State/Zip: ____________________________ Telephone:
				  _____________________
The Assisted Living and Shared Housing Act requires every
				  resident, prior to admission, annually and upon identification of significant
				  change in condition, to receive a comprehensive physician's assessment. The
				  assessment must include an evaluation of the person's physical, cognitive, and
				  psychosocial condition.
The Act prohibits persons having certain conditions or
				  limitations and requiring certain types of care from residing in an
				  establishment. A list of these conditions, limitations, and types of care
				  appears in
Part III
of this form.
Part I - I certify that the following have been
				  completed:
a physical, psychosocial, and cognitive
				  assessment;
written instructions for any needed home health
				  services, including periodic nutritional and skin integrity assessments;
				  and
instructions, as appropriate, contained in
Part II
of this form.
I further certify that in my professional
				  judgement the person for whom this certification is being completed meets the
				  conditions, limitations, and care requirements specified in the Assisted Living
				  and Shared Housing Act and outlined in
Part III
of this
				  form.
Signature:
Physician Name:
______________________________________________
(typed or printed)
Physician ID Number:
__________________________________________
Part II - Personal Services Needs:
Based on my
				  assessment, the resident's condition warrants assistance with the following
				  personal services: (note any specific needs and instruction)
Activity of Daily Living (ADL)
NO
YES
EXPLANATION
Eating
_______
_______
_________________
Does resident have any special dietary needs?
_______
_______
_________________
Dressing
_______
_______
_________________
Toileting
_______
_______
_________________
Transferring
_______
_______
_________________
Bathing
_______
_______
_________________
Personal Hygiene
_______
_______
_________________
Can resident administer his/her own
							 medication?
_______
_______
_________________
Does resident require supervision when taking
							 medications?
_______
_______
_________________
Does resident require establishment personnel to
							 administer medication?
_______
_______
_________________
Part III - Residency Conditions, Care and
				  Limitations
MUST
- be an adult
- pose no serious threat to anyone (including self)
- be able to communicate needs
- not have a severe mental illness
NOT NEED
- total assistance with 2 or more ADLs*
- assistance from more than 1 paid caregiver for any
				  ADL*
- more than minimal assistance to move to safe area in case
				  of emergency*
- 5 or more skilled nursing visits per week for conditions
				  other than treatment of stage 3 or stage 4 decubitus ulcers (for a period not
				  to exceed 3 consecutive weeks)
NOT NEED (unless self-administered or administered by a
				  qualified licensed health care professional)
- intravenous and/or gastrostomy feeding therapies
- insertion, sterile irrigation, and replacement of catheter,
				  except for routine maintenance*
- sterile wound care
- sliding scale insulin administration and injections
- treatment of stage 3 or stage 4 decubitus ulcers or
				  exfoliative dermatitis
* Except for quadriplegic, paraplegic, or individuals with
				  neuro-muscular disease