(a)

1. (1) If the resident needs assessment or evaluation indicates that the resident requires healthcare services, a written healthcare service plan shall be completed and become a part of the resident’s occupancy admission agreement within thirty (30) days of the date of admission by a registered nurse using an assessment instrument that meets the requirement of subsection (b) of this section.
2. (2) Based on the healthcare assessment, a written healthcare service plan shall be developed as part of the resident’s occupancy admission agreement.

3. (3) The healthcare service plan shall include, but not be limited to, the following:

   1. (A) Orders for treatment or services, medications, and diet, if needed;
   2. (B) The resident’s needs and preferences;
   3. (C) The specific goals of treatment or services, if appropriate;
   4. (D) The time intervals at which the resident’s response to treatment will be reviewed; and
   5. (E) The measures to be used to assess the effects of treatment.

(b) Each resident healthcare assessment shall include, at a minimum, evaluation of the following:

1. (1) Physical health, status, and abilities, including but not limited to:

   1. (A) Functional limitations and capacities;
   2. (B) Ability to self-administer medication;
   3. (C) Strengths, abilities, and capacity for self-care;
   4. (D) Disease diagnosis;
   5. (E) Oral and dental status;
   6. (F) Nutritional status and needs;
   7. (G) Skin conditions; and
   8. (H) Continence;

2. (2) Mental and emotional health, including but not limited to:

   1. (A) Mood and behavior patterns;
   2. (B) Ability to self-administer medications;
   3. (C) Cognitive patterns; and
   4. (D) Strengths, abilities, and capacity for self-care;
3. (3) Medications;
4. (4) Social and leisure needs and preferences;
5. (5) Communication and hearing patterns;
6. (6) Visual patterns;
7. (7) Situations or conditions that could put the resident at risk of harm or injury;
8. (8) Frequency of monitoring that the resident’s condition requires; and
9. (9) Special treatment and procedures.

(c)

1. (1) If the resident does not need a healthcare service, a healthcare service plan does not have to be included in the resident’s occupancy admission agreement.
2. (2) However, the facility must document that the healthcare assessment was performed and that the resident does not have any healthcare service needs.
3. (3) Assessment of the healthcare services needs of all residents in the facility shall be performed at least annually, except that those residents who have a healthcare services plan portion of the occupancy admission agreement shall be reassessed quarterly and revisions made as needed.
4. (4) The healthcare services plan portion of the occupancy admission agreement shall be revised within fourteen (14) days upon any significant change to the resident.