OAR 411-086-0060: Comprehensive Assessment and Care Plan

(1) Comprehensive Assessment: (a) An RN shall ensure completion and documentation of a comprehensive assessment of the resident's capabilities and needs for nursing services within 14 days of admission. Comprehensive assessments shall be updated promptly after any significant change of condition and reviewed no less often than quarterly. This assessment shall be on a form specified by the Division. The assessment shall include the following: (A) Medically defined conditions and medical history; (B) Medical status measurement; (C) Functional status; (D) Sensory and physical impairments; (E) Nutritional status and requirements; (F) Treatments and procedures; (G) Psychosocial status (see OAR 411-086-0240); (H) Discharge potential (see OAR 411-086-0160); (I) Dental condition; (J) Activities potential (see OAR 411-086-0230); (K) Rehabilitation and restorative potential (see OAR 411-086-0150 and 411-086-0220); (L) Cognitive status; and (M) Drug therapy. (b) Social services, activities and dietary personnel shall complete an assessment within 14 days of admission. (2) Care Plan Preparation and Implementation. The facility, through the nursing services department and the interdisciplinary staff, shall provide services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident in accordance with a written, dated, care plan: (a) The plan shall be completed within seven days after completion of the comprehensive assessment. The care plan shall be reviewed and updated whenever the resident's needs change, but no less often than quarterly; (b) The care plan shall describe the medical, nursing, and psychosocial needs of the resident and how the facility will actively meet those needs. This description of needs shall include measurable objectives and time frames in which the objectives will be met; (c) The plan shall provide for and promote personal choice and independence of the resident; (d) The resident care plan must address the following, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (e) The plan shall be reviewed and completed at an interdisciplinary care planning conference with participation from the resident's RN care manager and personnel from dietary, activities and social services. The resident's attending physician will participate in the development and any revision of the care plan. Physician participation may be in person, through communication with the DNS or RN Care Manager, or via telephone conference; (f) The resident, the resident's legal representative, and anyone designated by the resident shall be requested to participate. The request shall be documented in the resident's clinical record; (g) The plan shall be prepared and implemented with participation of the resident and in accordance with the resident's wishes; (h) Unless required or allowed by state or federal law, a facility shall not disclose any personally identifiable information regarding: (A) A resident’s sexual orientation; (B) Whether a resident is LGBTQIA2S+; (C) A resident’s gender transition status; or (D) A resident’s human immunodeficiency virus status. (i) The facility shall take appropriate steps to minimize the likelihood of inadvertent or accidental disclosure of information described in subsection (h) of this section to other residents, visitors or facility staff, except to the minimum extent necessary for facility staff to perform their duties. (j) Facilities must notify the resident or resident’s representative if the facility inadvertently or accidentally discloses such information to unauthorized persons. (k) The plan shall include an assessment of the resident's potential for discharge and the facility's efforts to work toward discharge; (l) The plan shall be available to and followed by all staff involved with care of the resident. (3) Documentation: (a) The care plan shall be written in ink and made a part of the resident's clinical record; (b) Participation in development of the care plan by interdisciplinary staff will be clearly documented.