Resident Assessment Form PDF Details

Preparing for a person's entry into an assisted living residence requires meticulous planning and understanding of their needs and capabilities to ensure they receive the appropriate level of support. The Resident Assessment Form used by the Commonwealth of Pennsylvania is a comprehensive instrument designed to capture crucial information within various domains such as personal information, health problems, medications, mobility, emergency evacuation needs, personal care needs, dietary preferences, healthcare management, housekeeping abilities, miscellaneous daily living tasks, communication capabilities, and behavioral or cognitive conditions. This form must be completed either within 30 days prior to admission or within 15 days following admission, and it is also required annually or in the event of a significant change in the resident's needs. Such thorough assessments guide the formulation of individualized care plans, ensuring each resident's health, safety, and well-being are proactively managed. Additionally, the form looks into preferences and interests, thereby personalizing the care and enhancing the quality of life in the assisted living setting. Furthermore, it outlines specific excludable conditions that may necessitate additional approval from the Department of Health to ensure the facility can adequately meet the needs of those requiring more intensive support.

QuestionAnswer
Form NameResident Assessment Form
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namespennsylvania residence resident assessment form, TIA, COPD, selfadministration

Form Preview Example

Commonwealth of Pennsylvania

ASSISTED LIVING RESIDENCE LICENSING

RESIDENT ASSESSMENT FORM

55 Pa.Code § 2800.22(a)(2), 2800.224(a), 2800.225

(To be completed within 30 days prior to admission or within 15 days after admission if certain conditions apply, annually and if significant change in resident needs)

Type of Assessment:

Initial Admission

Annual

Significant Change

 

Date of Assessment: ______________

Date of Admission __________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RESIDENT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

Name (First, MI, Last)

 

 

 

 

 

 

 

Date of Birth (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex

 

Marital Status

 

 

 

 

 

 

 

 

Rm/Apt. #

 

Male

Female

Single

Married

Divorced/Separated

Widow(er)

 

 

 

 

 

Is Able to Safely Operate Key-Locking Devices

Yes

No

 

 

Is a Veteran

Yes

No

 

 

 

 

 

 

 

 

 

 

 

Is Able to Safely Use Poisonous Personal Care and Toiletry Items

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is Able to Safely Use Other Poisons (such as cleaning supplies)

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEALTH PROBLEMS (Check All That Currently Apply)

 

 

 

 

 

Anemia

 

 

 

 

 

Hearing impairment (H.O.H., deafness)

 

 

 

 

Arthritis and other joint limitations or injuries

 

 

Heart trouble (angina, CHF, MI)

 

 

 

 

Bowel/bladder problems

 

 

 

 

Hypertension

 

 

 

 

 

Brain Injury (stroke, CVA, TIA, memory loss)

 

 

Mental Illness

 

 

 

 

 

Cancer, Leukemia or tumor

 

 

 

Respiratory problems (asthma, emphysema, COPD)

 

 

Dementia (OBS, Alzheimer’s, Huntington’s, Pick’s)

 

 

Skin Problems (decubitus ulcer, lesions, rashes)

 

 

 

 

 

 

 

 

Surgery with residual effects (drainage, amputation,

 

 

Developmental Disorder

 

 

 

 

paralysis, pain, fatigue)

 

 

 

 

 

Diabetes

 

 

 

 

 

Tremors (Parkinson’s)

 

 

 

 

 

Digestive disorders (ulcers, diverticulosis)

 

 

Visual impairments (cataracts, glaucoma, blindness)

 

 

Edema

 

 

 

 

 

Other (please list):

 

 

 

 

 

Effects of stroke (CVA, TIA, memory loss)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Effects of osteoporosis or fractures

 

 

 

 

 

 

 

 

 

 

 

Hardening of arteries (ASHD, poor circulation)

 

 

 

 

 

 

 

 

 

 

 

 

EXCLUDABLE CONDITIONS (Check All That Currently Apply)

 

 

 

 

A residence may not admit, retain or serve an individual with any of the below excludable conditions. The residence may submit a written request to the Department for an exception related to any of the identified conditions or health care needs to allow the residence to admit, retain or serve an individual with one of those conditions or health care needs.

 

 

 

Exception request submitted and

Exception request submitted;

 

 

 

 

 

 

 

 

 

approved by the Department?

pending Department approval

 

 

 

 

Ventilator dependency

 

Yes

No

 

 

 

 

 

 

 

Stage III and IV decubiti or vascular ulcers not in a

 

Yes

No

 

 

healing stage

 

 

 

 

 

 

 

 

Continuous intravenous fluids

 

Yes

No

 

 

 

 

 

 

 

Reportable infectious disease, such as TB, requiring

 

Yes

No

 

 

isolation and/or special precautions

 

 

 

 

 

 

 

 

Nasogastric tubes

 

Yes

No

 

 

 

 

 

 

 

Physical restraints

 

Yes

No

 

 

 

 

 

 

 

Continuous skilled nursing care 24 hours a day

 

Yes

No

 

 

 

 

 

 

 

Commonwealth of Pennsylvania

 

 

 

Resident Assessment Form

 

Office of Long-Term Living

Page 1

 

3/11

 

The following Excludable Conditions do not require an

 

 

 

 

 

 

If no, was

 

Exception

 

 

 

 

 

 

 

exception

 

request

 

exceptions request if the individual is capable of self-

 

Capable of self-administration/

 

 

 

 

 

request

 

submitted;

 

administration/ self-care or administered by a licensed health

 

 

care or administered by

 

 

 

 

 

 

 

 

submitted and

pending

 

professional/other qualified individual:

 

 

 

 

licensed health profession/other

 

 

 

 

 

 

 

approved by

Department

 

 

 

 

 

 

 

qualified individual

 

 

 

 

 

 

 

 

 

 

 

the

 

approval

 

 

(check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Department?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gastric tubes

 

 

 

 

 

Yes

No

 

 

Yes

No

 

 

Tracheostomy

 

 

 

 

 

Yes

No

 

 

Yes

No

 

 

Sliding scale insulin administration

 

 

 

 

 

Yes

No

 

 

Yes

No

 

 

Intermittent intravenous therapy

 

 

 

 

 

Yes

No

 

 

Yes

No

 

 

Insertions, sterile irrigation and replacement of a

 

 

 

Yes

No

 

 

Yes

No

 

 

catheter

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Oxygen

 

 

 

 

 

Yes

No

 

 

Yes

No

 

 

Inhalation therapy

 

 

 

 

 

Yes

No

 

 

Yes

No

 

 

Skilled nursing care 24 hours a day provided on a

 

 

 

Yes

No

 

 

Yes

No

 

 

temporary or intermittent basis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICATIONS (List All Current Medications at Time of Assessment)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prescription Medications

Dosage

 

Frequency

 

Physician/Pharmacy

Reason for Medication/Comments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Non-prescription/OTC Medications

Dosage

Frequency

Reason for Medication/Comments

Commonwealth of Pennsylvania

 

Resident Assessment Form

Office of Long-Term Living

Page 2

3/11

MEDICATION ADMINISTRATION

Can self-administer medications with no assistance from others

Can self-administer medications with assistance to store medications in a secure place

Can self-administer medications with assistance in remembering schedule

Can self-administer medications with assistance in offering medications at prescribed times

Can self-administer medications with assistance opening container or locked storage area

OR

Cannot self-administer medications

MOBILITY

Independent

Requires

Requires

 

 

with or

Requires full

 

prompting or

physical

 

without

physical

N/A

cueing to

assistance to

assistive

assistance

 

complete

complete

 

devices

 

 

 

 

 

 

Ambulatory

Transfer To/From Bed

Transfer To/From Chair

Transfer To/From Wheelchair

Turning and Positioning in Bed/Chair

Mobility Aids

None Wheelchair

Walker

Cane

Braces/Prostheses

Other (specify) ______________

EMERGENCY EVACUATION - Mobility Needs: In the event of an emergency, how much assistance does the applicant require to vacate the building? (Check All Applicable)

Unable to move from one location to another without physical assistance from others

Unable to move from one location to another without oral prompting from others

Difficulty understanding and following oral directions in the event of an emergency

Independently mobile with ambulation device

Walks without assistance

RESIDENT NEED FOR ASSISTANCE

 

 

 

 

Independent

 

Requires

 

Requires

 

 

 

 

 

 

 

 

with or

 

 

 

Requires full

 

 

 

 

 

 

 

prompting or

 

physical

 

 

 

 

 

 

 

without

 

 

 

physical

 

N/A

 

 

 

 

 

cueing to

 

assistance to

 

 

 

 

 

 

assistive

 

 

 

assistance

 

 

 

 

 

 

 

complete

 

complete

 

 

 

 

 

 

 

devices

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL CARE – Grooming/Bathing

 

 

 

 

 

 

 

 

 

 

 

 

Bathing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dental/Mouth Care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hair Care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Shaving

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Toe/Fingernail Care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL CARE - Toileting

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bladder Control

 

 

 

 

 

 

 

 

 

 

 

Bowel Control

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Special Equipment Required

 

 

 

 

 

 

 

 

 

 

 

List:

 

 

 

 

 

 

 

 

 

 

 

Catheter/Ostomy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PERSONAL CARE – Dressing/Undressing

 

 

 

 

 

 

 

 

 

 

 

 

Commonwealth of Pennsylvania

 

 

 

 

 

 

 

Resident Assessment Form

 

Office of Long-Term Living

 

 

 

Page 3

 

 

 

 

3/11

Undergarments

Shirts/Blouses/Sweaters

Pants

Shoes

Other (specify)

 

 

 

 

Independent

 

Requires

 

Requires

 

 

 

 

 

 

 

 

with or

 

 

 

 

Requires full

 

 

 

 

 

 

 

 

prompting or

 

physical

 

 

 

 

 

 

 

without

 

 

 

 

physical

 

N/A

 

 

 

 

 

 

cueing to

 

assistance to

 

 

 

 

 

 

assistive

 

 

 

assistance

 

 

 

 

 

 

 

complete

 

complete

 

 

 

 

 

 

 

devices

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DIETARY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eating

 

 

 

 

 

 

 

 

 

 

 

 

Drinking

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chewing/Swallowing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Meal Preparation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recent Weight Loss/Gain

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Uses Feeding Tubes/Devices

 

Yes

No

 

 

 

 

 

 

 

 

 

Calculated Diet Prescribed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Special Diet Followed

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Special Dietary Needs: (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HEALTHCARE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Securing Healthcare Services

 

 

 

 

 

 

 

 

 

 

 

 

Managing Healthcare Needs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOUSEKEEPING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cleans Bedroom, Bathroom, Kitchen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Personal Laundry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Make/Change Bed Linens

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Empty Own Trash

 

 

 

 

 

 

 

 

 

 

 

 

MISCELLANEOUS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Shopping

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Securing and Using Transportation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Managing Finances

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Using the Telephone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Making and Keeping Appointments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Caring for Personal Possessions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Writing Correspondence

 

 

 

 

 

 

 

 

 

 

 

 

Engaging in Social and Leisure Activities

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Using a Prosthetic Device

 

 

 

 

 

 

 

 

 

 

 

 

Obtaining Clean, Seasonal Clothing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMMUNICATION

 

 

 

 

 

 

 

Ability to Hear

 

 

 

 

 

 

 

 

 

 

 

 

No impairment

 

 

 

 

 

 

 

 

 

 

 

 

Impairment evident but not does not interfere with everyday functioning

 

 

 

 

 

 

 

Impairment interferes with everyday functioning

 

 

 

 

 

 

 

 

 

 

Minimal hearing even with device

 

 

 

 

 

 

 

 

 

 

 

 

No hearing even with device

 

 

 

 

 

 

 

 

 

 

 

 

Hears with device: Device ________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Commonwealth of Pennsylvania

 

 

 

 

 

 

 

 

Resident Assessment Form

 

Office of Long-Term Living

 

 

 

 

Page 4

 

 

 

 

3/11

Ability to See

No impairment

Impairment evident but does not interfere with everyday functioning

Impairment interferes with everyday functioning

Minimal vision even with device

No vision even with device

Sees with device: Device _________________________

Understanding Instructions

No impairment

Impairment evident but not does not interfere with everyday functioning

Impairment interferes with everyday communication or is significant enough to require the use of an alternative mode of communication - Alternative mode (specify): ___________________________

Minimal communication ability with or without the use of an alternative mode of communication No communication ability

Ability to Communicate Needs and Articulate Thoughts

No impairment

Impairment evident but not does not interfere with everyday functioning

Impairment interferes with everyday communication or is significant enough to require the use of an alternative mode of communication - Alternative mode (specify): ___________________________

Minimal communication ability with or without the use of an alternative mode of communication No communication ability

BEHAVIORAL/COGNITIVE CONDITION

 

 

 

Current problem but

Problem interferes

Severe problem that

 

 

No Problem

does not interfere with

with every day

 

 

requires intervention

 

 

 

every day functioning

functioning

 

 

 

 

 

Orientation to Date, Day, and

 

 

 

 

 

Place

 

 

 

 

 

 

 

 

 

 

 

Memory

 

 

 

 

 

 

 

 

 

 

 

Irritability

 

 

 

 

 

 

 

 

 

 

 

Judgment

 

 

 

 

 

 

 

 

 

 

 

Aggression

 

 

 

 

 

 

 

 

 

 

 

Anxiety

 

 

 

 

 

 

 

 

 

 

 

Depression

 

 

 

 

 

 

 

 

 

 

 

Wandering

 

 

 

 

 

 

 

 

 

 

 

Sociability

 

 

 

 

 

 

 

 

 

 

 

Socially Inappropriate/Disruptive

 

 

 

 

 

Behavior

 

 

 

 

 

Hallucinations/Delusions/

 

 

 

 

 

Paranoia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RESIDENT PREFERENCES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Leisure Activities and Interests

 

 

 

List all hobbies, interests or leisure activities the resident enjoys:

Commonwealth of Pennsylvania

 

Resident Assessment Form

Office of Long-Term Living

Page 5

3/11

Does the resident need or use any type of adaptive equipment to participate in hobbies, interests or leisure activities of choice? (specify)

Religious

Resident’s religious affiliation, if any:

 

Does the resident wish to participate in religious practices or services?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

Socialization

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the resident like to go out and do things with other people?

Yes

No

 

 

 

 

 

 

 

 

 

 

Does the resident belong to or participate in any clubs or organizations?

Yes

No If yes, list:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pets (If permitted by the facility)

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the resident have a pet that will reside in the facility/resident’s living unit?

Yes

No

If yes, type of pet:

 

 

 

 

 

 

 

Does the pet have a current certificate of rabies vaccination from a licensed veterinarian?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Firearms and Weapons (If permitted by the facility)

 

 

 

 

 

 

 

 

 

 

Does the resident own firearms, weapons or ammunition that will be stored in a locked cabinet/area of the facility?

Yes No

Has the resident been made aware and understands the facility’s policy regarding the safety, access and use of firearms, weapons and

ammunition? Yes No

Personal Vehicle/Transportation (If permitted by the facility)

Resident has personal vehicle and can drive self

Yes

No

Resident has a valid driver’s license. Yes No

FORMAL SUPPORTS

List all physicians/clinics and other health providers. Provide contact information.

State the condition for which the health provider is being seen.

Doctor/Clinic Name

Address

Phone Number

Condition

Commonwealth of Pennsylvania

 

Resident Assessment Form

Office of Long-Term Living

Page 6

3/11

INFORMAL SUPPORTS

List Family and Friends. Provide contact information

Name

Address

Phone Number

Relationship

DOCUMENTATION OF PARTICIPATION

Who assisted in completing the assessment (check all that are applicable):

Resident

 

Name

 

 

 

 

 

Address:

 

Resident’s family member

 

 

Telephone:

 

 

 

 

 

Signature:

 

 

 

 

 

Relationship to resident:

 

 

 

 

 

Name

 

 

 

 

Resident’s designated

Address:

 

 

 

 

 

person

Telephone:

 

 

 

 

 

Signature:

 

 

 

 

 

Relationship to resident:

 

 

 

 

Other

Name

 

 

 

 

Commonwealth of Pennsylvania

 

Resident Assessment Form

Office of Long-Term Living

Page 7

3/11

Other

Address:

Telephone:

Signature:

Relationship to resident:

Name

Address:

Telephone:

Signature:

Relationship to resident:

Name

Residence

Title

Signature

Name

Residence

Title

Signature

CERTIFICATION

Certification shall be made, prior to admission, that the needs of the potential resident can be met by the services provided by the

residence. The certification shall be made by the administrator of the residence acting in consultation with the supplemental health care providers; the individual’s physician or certified registered nurse practitioner; or the medical director of the residence.

Yes

Resident meets the criteria for admission to the assisted living residence.

Yes

The assisted living residence certifies that the potential resident’s needs can be met by the services provided by the assisted

 

living residence

No

The assisted living residence cannot meet the needs of the potential resident. (A written decision, including the basis for denial of

 

admission, shall be provided to the potential resident or his/her designated person)

Signature:

Title:

Date: (mm/dd/yyyy)

Commonwealth of Pennsylvania

 

Resident Assessment Form

Office of Long-Term Living

Page 8

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