10- 144 C.M.R. ch. 110, § 12 Pre-Admission Screening, Comprehensive Assessments and Plans of Care

• Library: Maine Administrative Code
• Edition: 2023
• Currency: Current through 2023-52, December 27, 2023
• Citation: 10- 144 C.M.R. ch. 110, § 12
• Year: 2023

12.A. Pre-Admission Screening

Facilities may not admit any resident who has not had a pre-admission screening for mental illness and/or mental retardation.

12.A.1. Definition: For the purposes of this Chapter: a. Mental Illness An individual is considered to be mentally ill if the individual has a primary or secondary diagnosis of a mental disorder as defined in the American Psychiatric Association Diagnostic and Statistical Manual (DSM-III 1R), 4th edition, and which does not include dementia. b. Mental Retardation An individual is considered to be "mentally retarded" if there is "significantly subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period".

12.A.2. Individuals With a Diagnosis or Suspicion of Mental Illness Prior to admission, the state mental health authority must determine, based on biopsychosocial evaluation performed by a person or entity other than the State mental health authority whether the individual has a diagnosis of mental illness and whether the individual requires acute and/or "specialized services".

12.A.3. Individuals With Mental Retardation or Related Condition(s) The Department of Mental Health, Mental Retardation and Substance Abuse Services determines prior to admission whether the individual requires "specialized services" for mental retardation.

12.B. Comprehensive Assessment

Each resident of a nursing facility shall have a comprehensive assessment which will enable facility staff to develop a plan of care designed to assist the resident to reach the highest practicable level of physical, mental, and psychosocial functioning.

12.B.1. Definitions a. Comprehensive Assessment 1. The comprehensive assessment includes the resident's medical, nursing and psychosocial history before admission and current medical diagnoses. 2. The comprehensive assessment must include:a. Identification and demographic information: b. Customary routine; c. Cognitive patterns; d. Communication; e. Vision; f. Mood and behavior patterns; g. Psychosocial well-being; h. Physical functioning and structural problems; i. Continence; j. Disease diagnosis and health conditions; k. Dental and nutritional status; l. Skin conditions; m. Activity pursuit; n. Medications; o. Special treatments and procedures; p. Discharge potential; q. Documentation of summary information regarding the additional assessment performed through the resident assessment protocols; r. Documentation of participation in assessment. b. Minimum Data Set (MDS) The Minimum Data Set (MDS) is the state approved assessment instrument which is the current core set of screening, clinical and functional status elements that forms the foundation of the comprehensive assessment for all residents in nursing facilities. The MDS must be completed up...