Section 481.65.11. Evaluation services.

Each resident admitted shall have a physical examination and tuberculin test no more than 30 days before admission and a physical examination annually after that. Each annual examination shall be sufficient to ensure the resident has no physical condition which precludes living in the facility. If the resident is admitted directly from a hospital, a copy of the hospital admission physical and discharge summary may meet this requirement. (II, III)

       65.11(1) In addition to the required initial physical examination, each resident shall be evaluated to identify physical health, current level of functioning and the need for services. This evaluation shall be completed within 30 days of admission and annually after that. Information from other sources may be used in the evaluation if the information meets the requirements of subrules 65.11(2) and 65.11(3). (II, III)

       65.11(2) The portion of the evaluation which describes the resident’s physical health shall:

        a.           Identify current illnesses and disabilities and include recommendations for physical and physiological treatment and services; (II, III)

        b.           Include a description of the resident’s ability for health maintenance; (II)

        c.           Include a mental status examination and history of mental health and treatments; (II, III) and

        d.           Be performed by a physician with a valid license to practice medicine and surgery, osteopathic medicine and surgery or osteopathy in Iowa. If the evaluation is not conducted in Iowa, it must be by a physician who holds a current license in the state in which the examination is performed. If the doctor is not a psychiatrist, a psychiatrist or health service provider in psychology licensed under Iowa Code section 154B.7 shall be consulted regarding the results of the mental status examination. (II, III)

       65.11(3) The portion of the evaluation which describes the resident’s current functioning level and need for services shall:

        a.           Identify the functioning level and need for services in self-care, community living skills, psychotherapeutic treatment, vocational skills, and academic skills as appropriate; (II, III)

        b.           Contain sufficient detail about skills and needs to determine appropriate placement; (II, III)

        c.           Be made without regard to the availability of services; (III) and

        d.           Be performed by a QMHP, consulting with an interdisciplinary team. (III)

       65.11(4) Results of all evaluations shall be in writing and maintained in resident records. After the initial evaluation, all subsequent evaluations shall contain sufficient detail to determine changes in the resident’s physical and mental health, skills, and need for services. (II, III)

       65.11(5) A narrative social history shall be completed for each resident within 30 days of admission. The social history shall be completed and approved by the qualified mental health professional before the IPP is developed. (III)

        a.           When a social history is secured from another provider, the information shall be reviewed within 30 days of admission. The date of the review and a summary of significant changes in the information shall be entered in the resident’s record. The social worker who reviews the history shall sign it. (III)

        b.           An annual review of the social history information shall be incorporated in the individual program plan progress notes. (III)

        c.           The social history shall address at least the following areas:

       (1)             Referral source and reason for admission; (II, III)

       (2)             Legal status; (II, III)

       (3)             Previous living arrangements; (III)

       (4)             Services received previously and current service involvements; (II, III)

       (5)             Significant medical and mental health conditions including at least illnesses, hospitalizations, past and current drug therapy, and special diets; (II, III)

       (6)             Substance abuse history; (II, III)

       (7)             Work history; (III)

       (8)             Education history; (II)

       (9)             Relationship with family, significant others, and other support systems; (III)

       (10)           Cultural, ethnic and religious background; (II, III)

       (11)           Hobbies and leisure time activities; (III)

       (12)           Likes, dislikes, habits, and patterns of behavior; (II, III)

       (13)           History of aggressive or suicidal behavior; (I, II, III) and

       (14)           Impressions and recommendations. (II, III)

This rule is intended to implement Iowa Code section 135C.14(7).