(1) Within 21 days of admission to a category B status, the administrator or designee shall assure that a written resident health care assessment is performed on each category B resident.

(2) Each initial health care assessment by the licensed health care professional shall include, at a minimum, evaluation of the following:

(a) cognitive status;

(b) communication/hearing patterns;

(c) vision patterns;

(d) physical functioning and structural problems;

(e) continence;

(f) psychosocial well being;

(g) mood and behavior patterns;

(h) activity pursuit patterns;

(i) disease diagnosis;

(j) health conditions;

(k) oral nutritional status;

(l) oral dental status;

(m) skin condition;

(n) medication use; and

(o) special treatment and procedures.

(3) A written resident health care plan shall be developed. The resident health care plan shall include, but not be limited to the following:

(a) a statement which informs the resident and the resident's practitioner, if applicable, of the requirements of 50-5-226 (3) and (4) , MCA.

(b) orders for treatment or services, medications and diet, if needed;

(c) the resident's needs and preferences for themselves;

(d) the specific goals of treatment or services, if appropriate;

(e) the time intervals at which the resident's response to treatment will be reviewed; and

(f) the measures to be used to assess the effects of treatment;

(g) if the resident requires care or supervision by a licensed health care professional, the health care plan shall include the tasks for which the professional is responsible.

(4) The category B resident's health care plan shall be reviewed, and if necessary revised upon change of condition.

(5) The health care plan shall be readily available to and followed by those staff and licensed health care professionals providing the services and health care.

History: Sec. 50-5-103, 50-5-226 and 50-5-227, MCA; IMP, Sec. 50-5-225, 50-5-226 and 50-5-227, MCA; NEW, 2002 MAR p. 3638, Eff. 12/27/02.