§ 87458 — Medical Assessment

(a)  Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

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

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

  (1)  A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following:

    (A)  Communicable tuberculosis.

    (B)  Infectious diseases.

    (C)  Contagious diseases.

    (D)  Other medical conditions.

  (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, Incidental Medical and Dental Care Services.

  (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, Definitions, or bedridden as defined in Health and Safety Code section 1569.72. The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition, or both.

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    Health and Safety Code section 1569.72 provides in part:

    "(b)(1)  For the purposes of this section, 'bedridden' means requiring assistance in turning and repositioning in bed or being unable to independently transfer to and from bed, except in a facility with appropriate and sufficient care staff, mechanical devices, if necessary, and safety precautions, as determined by the director in regulations."

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  (6)  Cognitive conditions, such as MCI and major NCD as defined in Section 87101, Definitions.

  (7)  A description of any known behavioral expression as defined in Section 87101, Definitions.

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

NOTE:  Authority cited:  Section 1569.30, Health and Safety Code.  Reference:  Sections 1569.1, 1569.2, 1569.31, 1569.312, 1569.315 and 1569.54, Health and Safety Code.