NURSING ASSESSMENT DETAILS

An assessment is a DSHS required document for all residents wishing to move into or who already reside in an Adult Family Home in Washington State. The assessment must be done and contain accurate information about the resident’s current needs and preferences. It is used as a tool to get to know the resident and their care-planning needs. 

The provider must be knowledgeable about the resident’s current needs and preferences before an AFH provider can admit a resident to their home. AFH providers will use the preliminary service information along with the assessment to create a Negotiated Care plan within 30 days of admission.

The AFH provider must ensure the assessment contains the minimum information required as listed in WAC 388-76-10335. I Care's Assessment meets the minimum requirements and more. 

MINIMUM REQUIREMENTS 

• (1) Recent medical history;
• (2) Current prescribed medications, and contraindicated medications, including but not limited to, medications known to cause adverse reactions or allergies;
• (3) Medical diagnosis reported by the resident, the resident representative, family member, or by a licensed medical professional;
• (4) Medication management:
  • (a) The ability of the resident to be independent in managing medications;
  • (b) The amount of medication assistance needed;
  • (c) If medication administration is required; or
  • (d) If a combination of the elements in (a) through (c) above is required.
• (5) Food allergies or sensitivities;
• (6) Significant known behaviors or symptoms that may cause concern or require special care, including:
  • (a) The need for and use of medical devices; 
  • (b) The refusal of care or treatment; and
  • (c) Any mood or behavior symptoms that the resident has had within the last five years.
• (7) Cognitive status, including an evaluation of disorientation, memory impairment, and impaired judgment;
• (8) History of depression and anxiety;
• (9) History of mental illness, if applicable;
• (10) Social, physical, and emotional strengths and needs;
• (11) Functional abilities in relationship to activities of daily living including:
  • (a) Eating;
  • (b) Toileting;
  • (c) Walking;
  • (d) Transferring;
  • (e) Positioning;
  • (f) Personal hygiene;
  • (g) Dressing; and
  • (h) Bathing.
• (12) Preferences and choices about daily life that are important to the resident, including but not limited to:
  • (a) The food that the resident enjoys;
  • (b) Meal times; and
  • (c) Sleeping and nap times.
  • (13) Activities.

The preliminary service plan includes the resident’s specific problems, needs, goals, & preferences. It includes how safety & health will be promoted by meeting care needs & handling refusal of care. 

The assessment must be updated at least every 12 months, when there is a significant change in the resident’s physical or mental condition, when the negotiated care plan no longer reflects the resident’s status, needs, or preferences, and at the provider or resident’s request. 

The assessment takes between 30 minutes-1.5 hrs for the face to face. It is a very comprehensive document and takes several hours to type after the face-to face. Expected turn around to get the completed assessment back is between 5 days to 2 weeks. So it is good to plan ahead if possible.

The adult family home may only admit a resident to the home without an assessment or a preliminary service plan if a true emergency exists. To establish that a true emergency exists, the home must verify that the resident's life, health or safety is at serious risk due to circumstances in the resident's current place of residence or harm to the resident has occurred. The assessment must be done within 5 days of admission.