Assisted Living Assessments: Keeping it Simple (and Compliant)

Okay, let's talk assessment requirements in Minnesota. The rules can seem a bit fuzzy, especially when it comes to some of the required assessments and the time frames required. Keep in mind, all assessments must be completed by the Registered Nurse.

Since our facility is an ALF with Dementia Care, that's what I'll focus on. Here's my approach to staying compliant and keeping things running smoothly:

Before Move-In (Initial/Pre-Screen Assessment):  We prefer to do in person assessment when possible with potential residents and their families. I want to meet the person and family we will be caring for! This assessment is required before services are initiated. The Initial Assessment helps us know if we can meet the potential resident's needs and identify any potential risks. Ideally, this happens close to the move-in date (within 30 days), because, let's face it, a lot can change in a month! I prefer in-person for this one, but sometimes remote works too. From here, document all of your conversations with the resident or family on risks, admission planning with current facility or providers, and preparation for any equipment or supply needs. Inform your caregivers of the upcoming admission and the resident's needs. Let them know what to expect on admission day!

Move-In Day (Admission Assessment): This is the big one! I block off at least 4-6 hours for a thorough assessment, including ADLs, a physical check-up, fall risk, safety assessment, and a review of the pre-screen, ensuring the resident is well tucked in and has all supplies and medications then need before ending the day. This is also when I do the Medication Management Assessment (gotta be in person for that one!) and the Individual Abuse Prevention Plan. Plus, we also chat and complete an Activity and Dietary Preferences. This assessment is also a great time to make sure your caregivers are clear on the resident's care plan.

Two Weeks Later (14-Day Assessment): Within 14 days of move-in, you guess it! Another assessment is required. This is when I usually complete cognitive testing. Moving can be very disorientating to a cognitively impaired resident, this allows time for some delirium to clear. I aim for mornings when residents are usually at their best. I also review the Initial Assessment and services, now that I know the resident a little better.

Every 90 Days (Ongoing Assessment):  Regular check-ins are key...and required! At least every 90 days, I do at a minimum, a physical assessment, review meds and services, and check for any changes in ADLs, Fall and Safety Risk, Medication Management and the Individual Abuse Prevention Plan.

Once a Year (Annual Assessment):  Other than the required re-assessment of the Medication Management Assessment, there is no requirement for an Annual Assessment, but our facility completes this as our standard yearly review. This one covers everything! It's a deep dive into the resident's overall well-being, care plan, code status, and everything else. It also counts as one of the 90 day assessments if done within that time frame.

When Things Change (Change in Condition Assessment):  Any change in a resident – a fall, a new health issue, a change in transfer need (both increased need or even an improvement), a hospice admission – triggers a new assessment, and this isn't an exhaustive list! A good standard I follow is if I'm changing a service for a caregiver, there should also be a related assessment and care plan update. Usually in person, unless it's something straightforward like a non urgent hospice admission.

Weekends & Holidays:  Yep, we have to be ready for residents returning from the hospital even on weekends and holidays. This is now a requirement that not only helps get our resident's back home to recover quicker, but opens up beds in our local hospitals. Ideally, I like to see the resident in person upon return, but a remote assessment is okay if needed and you've received a detailed assessment report from the discharging hospital. However, I've learned that things aren't always what they seem even if you think you have all of the information you need, so I prefer to check in person whenever possible.

It might sound like a lot, but it becomes routine pretty quickly. A good charting system is a lifesaver!

And of course, we're always here to help if you have questions or need some advice. Just reach out!