Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 10 - DEPARTMENT OF HEALTH SERVICES - HEALTH CARE INSTITUTIONS: LICENSING › Article 4 - NURSING CARE INSTITUTIONS › Section R9-10-414 - Comprehensive Assessment; Care Plan

Current through Register Vol. 30, No. 28, July 12, 2024
A. A director of nursing shall ensure that:
1. A comprehensive assessment of a resident:
a. Is conducted or coordinated by a
				registered nurse in collaboration with an interdisciplinary team;
b. Is completed for the resident within 14
				calendar days after the resident's admission to a nursing care
				institution;
c. Is updated:
i. No later than 12 months after the date of
				the resident's last comprehensive assessment, and
ii. When the resident experiences a
				significant change;
d.
				Includes the following information for the resident:
i. Identifying information;
ii. An evaluation of the resident's hearing,
				speech, and vision;
iii. An
				evaluation of the resident's ability to understand and recall
				information;
iv. An evaluation of
				the resident's mental status;
v.
				Whether the resident's mental status or behaviors:
(1) Put the resident at risk for physical
				illness or injury,
(2)
				Significantly interfere with the resident's care,
(3) Significantly interfere with the
				resident's ability to participate in activities or social
				interactions,
(4) Put other
				residents or personnel members at significant risk for physical
				injury,
(5) Significantly intrude
				on another resident's privacy, or
(6) Significantly disrupt care for another
				resident;
vi.
				Preferences for customary routine and activities;
vii. An evaluation of the resident's ability
				to perform activities of daily living;
viii. Need for a mobility device;
ix. An evaluation of the resident's ability
				to control the resident's bladder and bowels;
x. Any diagnosis that impacts nursing care
				institution services that the resident may require;
xi. Any medical conditions that impact the
				resident's functional status, quality of life, or need for nursing care
				institution services;
xii. An
				evaluation of the resident's ability to maintain adequate nutrition and
				hydration;
xiii. An evaluation of
				the resident's oral and dental status;
xiv. An evaluation of the condition of the
				resident's skin;
xv. Identification
				of any medication or treatment administered to the resident during a seven-day
				calendar period that includes the time the comprehensive assessment was
				conducted;
xvi. Identification of
				any treatment or medication ordered for the resident;
xvii. A description of the resident or resident's
				representative's participation in the comprehensive assessment;
xviii. The name and title of the interdisciplinary
				team members who participated in the resident's comprehensive
				assessment;
xix. Potential for rehabilitation; and
xx.Potential for discharge; and
e. Is signed and dated by:
i. The registered nurse who conducts or
				coordinates the comprehensive assessment or review; and
ii. If a behavioral health professional is
				required to review according to subsection (A)(2), the behavioral health
				professional who reviewed the comprehensive assessment or review;