Authority: IC 16-28-1-7

Affected: IC 12-10-12; IC 16-28-5-1

Sec. 31. (a) The facility must make a comprehensive assessment of each resident's needs that describes the resident's capability to perform daily life functions and significant impairments in functional capacity.

(b) Comprehensive facilities must use an assessment instrument based on the uniform data set specified by the division. Facilities which are not certified by Medicare or Medicaid must comply with this subsection by April 1, 1999.

(c) The comprehensive assessment must include at least the following information:

1. (1) Medically defined conditions and prior medical history.
2. (2) Medical status measurement.
3. (3) Physical and mental functional status.
4. (4) Sensory and physical impairments.
5. (5) Nutritional status and requirements.
6. (6) Special treatments or procedures.
7. (7) Mental and psychosocial status.
8. (8) Discharge potential.
9. (9) Dental condition.
10. (10) Activities potential.
11. (11) Rehabilitation potential.
12. (12) Cognitive status.
13. (13) Drug therapy.

(d) The facility must conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity as follows:

1. (1) Assessments must be conducted no later than fourteen (14) days after the date of admission, and promptly after a significant change in the resident's physical or mental condition.
2. (2) Assessments shall be conducted at least once every twelve (12) months.
3. (3) The nursing facility must examine each resident no less than once every three (3) months, and, as appropriate, revise the resident's assessment to assure the continued accuracy of the assessment.

(e) The results of the assessment are used to develop, review, and revise the resident's comprehensive care plan.

(f) The facility must coordinate assessments with the state required preadmission screening program under IC 12-10-12 to the maximum extent practicable to avoid duplicative testing and effort.

(g) Each assessment must be conducted or coordinated with the appropriate participation of health professionals.

(h) Each assessment must be conducted or coordinated by a registered nurse who signs and certifies the completion of the assessment.

(i) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

(j) For purposes of IC 16-28-5-1, a breach of:

1. (1) subsection (a), (c), (d), or (e) is a deficiency; and
2. (2) subsection (b), (f), (g), (h), or (i) is a noncompliance.

(Indiana Department of Health; 410 IAC 16.2-3.1-31; filed Jan 10, 1997, 4:00 p.m.: 20 IR 1552, eff Apr 1, 1997; readopted filed Jul 11, 2001, 2:23 p.m.: 24 IR 4234; readopted filed May 22, 2007, 1:44 p.m.: 20070613-IR-410070141RFA; readopted filed Sep 11, 2013, 3:19 p.m.: 20131009-IR-410130346RFA; readopted filed Nov 13, 2019, 3:14 p.m.: 20191211-IR-410190391RFA; readopted filed Nov 14, 2025, 11:18 a.m.: 20251210-IR-410240588RFA)