Document Citation: 22 CCR 87458

Header:
CALIFORNIA CODE OF REGULATIONS
TITLE 22. SOCIAL SECURITY
DIVISION 6. LICENSING OF COMMUNITY CARE FACILITIES
CHAPTER 8. RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE)
ARTICLE 8. RESIDENT ASSESSMENTS, FUNDAMENTAL SERVICES AND RIGHTS

Date:
08/31/2009

Document:
22 CCR 87458 (2011)

§ 87458. Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

(b) The medical assessment shall include, but not be limited to:

(1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

(2) Documentation of prior medical services and history and current medical status including, but not limited to height, weight, and blood pressure.

(3) A record of current prescribed medications, and an indication of whether the medication should be centrally stored, pursuant to Section 87465(h)(1).

(4) Identification of physical limitations of the person to determine his/her capability to participate in the programs provided by the licensee, including any medically necessary diet limitations.

(5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both.

(6) Information applicable to the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal.

(c) The licensee shall obtain an updated medical assessment when required by the Department.