Virginia Administrative Code › Title 22 - SOCIAL SERVICES › Agency 40 - DEPARTMENT OF SOCIAL SERVICES › Chapter 745 - ASSESSMENT IN ASSISTED LIVING FACILITIES › Part II - Assessment Services › Section 22VAC40-745-30 - Determination of services to be provided

Current through Register Vol. 40, No. 24, July 15, 2024
A. The assessment shall be conducted with the
				  department-designated uniform assessment instrument which sets forth a
				  resident's care needs. The uniform assessment instrument is designed to be a
				  comprehensive, accurate, standardized, and reproducible assessment of
				  individuals seeking or receiving long-term care services. The uniform
				  assessment instrument is comprised of a short assessment and a full assessment.
				  The short assessment is designed to briefly assess the individual's need for
				  appropriate level of care and services and to determine if a full assessment is
				  needed. The uniform assessment instrument shall contain the following items:
				  Full name of the individual; social security number; current address; date of
				  birth; sex; marital status; racial/ethnic background; education; method for
				  communication of needs; primary caregiver or emergency contact or both; usual
				  living arrangements; problems with physical environmental; use of current
				  formal services; annual income; sources of income; legal representatives;
				  benefits or entitlements received; types of health insurance; performance on
				  functional status which includes ADLs, continence, ambulation and IADLs;
				  physician information; admissions to hospitals, nursing facilities or assisted
				  living facilities for medical or rehabilitation reasons; advance directives;
				  diagnoses and medication profile; sensory functioning; joint motion; presence
				  of fractures/dislocations; missing limbs or paralysis/paresis; nutrition;
				  smoking history; use of rehabilitation therapies; presence of pressure ulcers;
				  need for special medical procedures; need for ongoing medical/nursing needs;
				  orientation; memory and judgment; behavior pattern; life stressors; emotional
				  status; social history which includes activities, religious involvement;
				  contact with family and friends; hospitalization for emotional problems; use of
				  alcohol or drugs; assessment of caregivers; and an assessment
				  summary.
B. Sections of the uniform
				  assessment instrument which must be completed are as follows:
1. The assessment for private pay individuals
				  shall include the following portions of the uniform assessment instrument: name
				  of the individual; social security number; current address; birthdate; sex;
				  marital status; performance on functional status, which includes ADLs,
				  continence, ambulation, IADLs, medication administration, and behavior pattern.
				  In lieu of completing selected parts of the department-designated uniform
				  assessment instrument, the alternate uniform assessment instrument developed
				  for private pay applicants and residents may be used.
2. For public pay individuals, the short form
				  of the uniform assessment instrument shall be completed. The short form
				  consists of sections related to identification and background, functional
				  status, medication administration, and behavior pattern. If, upon assessment,
				  it is determined that the individual is dependent in at least two activities of
				  daily living or is dependent in behavior, then the full assessment must be
				  completed.