PDFWAC 388-97-1000
Resident assessment.
The department amended or suspended portions of this section from April 13, 2020, through May 10, 2021, in response to the state of emergency related to the COVID-19 pandemic. For requirements in place during that time, see WAC 388-97-10001.
(1) The nursing home must:
(a) Provide resident care based on a systematic, comprehensive, interdisciplinary assessment, and care planning process in which the resident participates, to the fullest extent possible;
(b) Conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity;
(c) At the time each resident is admitted:
(i) Have physician's orders for the resident's immediate care; and
(ii) Ensure that the resident's immediate care needs are identified in an admission assessment.
(d) Ensure that the comprehensive assessment of a resident's needs describes the resident's capability to perform daily life functions and significant impairments in functional capacity.
(2) The comprehensive assessment must include at least the following information:
(a) Identification and demographic information;
(b) Customary routine;
(c) Cognitive patterns;
(d) Communication;
(e) Vision;
(f) Mood and behavior patterns;
(g) Psychosocial well-being;
(h) Physical functioning and structural problems;
(i) Continence;
(j) Disease diagnosis and health conditions;
(k) Dental and nutritional status;
(l) Skin conditions;
(m) Activity pursuit;
(n) Medications;
(o) Special treatments and procedures;
(p) Discharge potential;
(q) Documentation of summary information regarding the assessment performed; and
(r) Documentation of participation in assessment.
(3) The nursing home must conduct comprehensive assessments:
(a) No later than 14 days after the date of admission;
(b) Promptly after a significant change in the resident's physical or mental condition; and
(c) In no case less often than once every 12 months.
(4) The nursing home must ensure that:
(a) Each resident is assessed no less than once every three months, and as appropriate, the resident's assessment is revised to assure the continued accuracy of the assessment; and
(b) The results of the assessment are used to develop, review, and revise the resident's comprehensive plan of care under WAC 388-97-1020.
(5) The skilled nursing facility and nursing facility must:
(a) For the required assessment, complete the state approved resident assessment instrument (RAI) for each resident in accordance with federal requirements;
(b) Maintain electronic or paper copies of completed resident assessments in the resident's active medical record for 15 months; this information must be maintained in a centralized location and be easily and readily accessible;
(c) Place the hard copies of the signature pages in the clinical record of each resident if a facility maintains their RAI data electronically and does not use electronic signatures;
(d) Assess each resident not less than every three months, using the state approved assessment instrument; and
(e) Transmit all state and federally required RAI information for each resident to the department:
(i) In a manner approved by the department;
(ii) Within 14 days of completion of any RAI assessment required under this subsection; and
(iii) Within 14 days of discharging or admitting a resident for a tracking record.
[Statutory Authority: RCW 74.42.620 and chapter 18.51 RCW. WSR 24-07-008, § 388-97-1000, filed 3/7/24, effective 4/7/24. Statutory Authority: Chapter 74.42 RCW and 42 C.F.R. 483.20. WSR 18-11-001, § 388-97-1000, filed 5/2/18, effective 6/2/18. Statutory Authority: Chapters 18.51 and 74.42 RCW. WSR 13-04-093, § 388-97-1000, filed 2/6/13, effective 3/9/13. Statutory Authority: Chapters 18.51 and 74.42 RCW and 42 C.F.R. 489.52. WSR 08-20-062, § 388-97-1000, filed 9/24/08, effective 11/1/08.]