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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

Is a Veteran

Yes

Is Able to Safely Use Poisonous Personal Care and Toiletry Items

Yes

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

Yes

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
		approved by the Department?		pending Department approval
Ventilator dependency		Yes	No
Ventilator dependency
Stage III and IV decubiti or vascular ulcers – not in a		Yes	No
healing stage		Yes	No
healing stage
Continuous intravenous fluids		Yes	No
Continuous intravenous fluids
Reportable infectious disease, such as TB, requiring		Yes	No
isolation and/or special precautions		Yes	No
isolation and/or special precautions
Nasogastric tubes		Yes	No
Nasogastric tubes
Physical restraints		Yes	No
Physical restraints
Continuous skilled nursing care 24 hours a day		Yes	No
Continuous skilled nursing care 24 hours a day
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

Tracheostomy

Yes

Sliding scale insulin administration

Yes

Intermittent intravenous therapy

Yes

Insertions, sterile irrigation and replacement of a

Yes

catheter

Oxygen

Yes

Inhalation therapy

Yes

Skilled nursing care 24 hours a day provided on a

Yes

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

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

with or

Requires full

prompting or

physical

without

physical

N/A

cueing to

assistance to

assistive

assistance

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

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3/11

Undergarments

Shirts/Blouses/Sweaters

Pants

Shoes

Other (specify)

Independent

Requires

with or

Requires full

prompting or

physical

without

physical

N/A

cueing to

assistance to

assistive

assistance

complete

devices

DIETARY

Eating

Drinking

Chewing/Swallowing

Meal Preparation

Recent Weight Loss/Gain

Yes

Uses Feeding Tubes/Devices

Yes

Calculated Diet Prescribed

Special Diet Followed

Yes

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)

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

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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	Severe problem that
	No Problem	does not interfere with	with every day	requires intervention
		every day functioning	functioning	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
	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

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
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	3/11

Question	Answer
Form Name	Resident Assessment Form
Form Length	8 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min
Other names	pennsylvania residence resident assessment form, TIA, COPD, selfadministration

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