Section 295.4000  Physician's Assessment

a)         No more than 120 days prior to admission of a resident to any establishment, a comprehensive assessment that includes an evaluation of the prospective resident's physical, cognitive, and psychosocial condition shall be completed by a physician. The physician's assessment shall include documentation of the presence or the absence of tuberculosis infection in accordance with the Control of Tuberculosis Code. At the time of admission, the physician's assessment must reflect the resident's current condition.

b)         At least annually, once a resident has moved into the establishment, a comprehensive assessment shall be completed by a physician.

c)         A physician's assessment shall be completed by a physician upon identification of a significant change in the resident's condition.

d)         When a physician's assessment is conducted pursuant to this Part, all current negotiated risk agreements shall be renegotiated as necessary.

e)         More frequent assessments of skin integrity and nutritional status shall be required (Section 15 of the Act) as ordered by the resident's physician and as arranged for by the resident.

f)         It is the responsibility of the resident or his/her representative to have physician's assessments and reassessments completed.

g)         Establishments may develop their own tools for evaluating their residents; however, the establishment evaluation does not replace the requirement for a physician's assessment. Documentation of evaluations and re-evaluations may be in any form that is accurate, that addresses the resident's condition, and that incorporates the physician's assessment.

h)                The establishment shall monitor and have a reporting procedure in place for notifying a relative or other individual in an emergency situation, significant change in resident's condition, or termination of residency.

i)          The establishment shall have policies in place to respond to the gradual deterioration of a resident's ability to carry out the activities of daily living that may accompany the aging process.

(Source:  Amended at 28 Ill. Reg. 14593, effective October 21, 2004)