North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 13 - NC MEDICAL CARE COMMISSION › Subchapter G - LICENSING OF FAMILY CARE HOMES › Section .0800 - RESIDENT ASSESSMENT AND CARE PLAN › Section 13G .0801 - RESIDENT ASSESSMENT

Current through Register Vol. 39, No. 2, July 15, 2024
(a) A family care
				  home shall assure that an initial assessment of each resident is completed
				  within 72 hours of admission using the Resident Register.
(b) The facility shall assure an assessment
				  of each resident is completed within 30 days following admission and at least
				  annually thereafter using an assessment instrument established by the
				  Department or an instrument approved by the Department based on it containing
				  at least the same information as required on the established instrument. The
				  assessment to be completed within 30 days following admission and annually
				  thereafter shall be a functional assessment to determine a resident's level of
				  functioning to include psychosocial well-being, cognitive status and physical
				  functioning in activities of daily living. Activities of daily living are
				  bathing, dressing, personal hygiene, ambulation or locomotion, transferring,
				  toileting and eating. The assessment shall indicate if the resident requires
				  referral to the resident's physician or other licensed health care
				  professional, a provider of mental health, developmental disabilities or
				  substance abuse services or a community resource.
(c) The facility shall assure an assessment
				  of a resident is completed within 10 days following a significant change in the
				  resident's condition using the assessment instrument required in Paragraph (b)
				  of this Rule. For the purposes of this Subchapter, significant change in the
				  resident's condition is determined as follows:
(1) Significant change is one or more of the
				  following:
(A) deterioration in two or more
				  activities of daily living;
(B)
				  change in ability to walk or transfer;
(C) change in the ability to use one's hands
				  to grasp small objects;
(D)
				  deterioration in behavior or mood to the point where daily problems arise or
				  relationships have become problematic;
(E) no response by the resident to the
				  treatment for an identified problem;
(F) initial onset of unplanned weight loss or
				  gain of five percent of body weight within a 30-day period or 10 percent weight
				  loss or gain within a six-month period;
(G) threat to life such as stroke, heart
				  condition, or metastatic cancer;
(H) emergence of a pressure ulcer at Stage
				  II, which is a superficial ulcer presenting an abrasion, blister or shallow
				  crater, or higher;
(I) a new
				  diagnosis of a condition likely to affect the resident's physical, mental, or
				  psychosocial well-being over a period of time such as initial diagnosis of
				  Alzheimer's disease or diabetes;
(J) improved behavior, mood or functional
				  health status to the extent that the established plan of care no longer matches
				  what is needed;
(K) new onset of
				  impaired decision-making;
(L)
				  continence to incontinence or indwelling catheter; or
(M) the resident's condition indicates there
				  may be a need to use a restraint and there is no current restraint order for
				  the resident.