Fillable PRE-SCREENING AND ASSESSMENT FOR ADMISSION TO ASSISTED LIVING (Missouri)

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PRE-SCREENING AND ASSESSMENT FOR ADMISSION TO ASSISTED LIVING (Missouri)

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YES
MO 580-2835 (9-06) PAGE 1
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
DIVISION OF REGULATION AND LICENSURE
SECTION FOR LONG-TERM CARE REGULATION
PRE-SCREENING AND ASSESSMENT FOR ADMISSION TO ASSISTED LIVING FACILITIES
PART I - PRE-SCREENING
NAME (FIRST, MIDDLE, LAST) SOCIAL SECURITY NUMBER
ADDRESS (STREET, CITY, STATE, ZIP)
PERSON IS CURRENTLY
Living Independently Living in Residential Care Facility Hospitalized
Other ______________________________________________________
COMMENTS
TELEPHONE DOB SEX
Male Female
MARITAL STATUS
Single Married Never Married Divorced/Separated Widow(er)
YES NO
YES
Disqualify
NO
Qualify
NO
Qualify
NO
Qualify
NO
Qualify
NO
Qualify
NO
YES
Disqualify
YES
Disqualify
YES
Disqualify
YES
Disqualify
Resident able to participate in providing above information?
Resident bed-bound or similarly immobilized?
Has the resident exhibited behaviors that present a reasonable likelihood of serious harm to self or
others?
Resident requires a physical restraint?
Resident uses a medication as a chemical restraint? (medication not used to treat a medical
condition)
Resident requires more than one person to simultaneously physically assist with any activities of
daily living other than bathing and/or transferring?
Resident has a condition that requires skilled nursing services? If yes, please list:
TO BE DETERMINED BY PERSON DOING RESIDENT ASSESSMENT
Yes Resident meets criteria for admission to Assisted Living Facility. Proceed to complete a community based assessment using the
attached or a form which has received prior approval from the Section for Long Term Care Regulation.
Yes Resident meets criteria for admission to Assisted Living Facility which provides services to residents with a physical, cognitive or
other impairment that prevents the resident from safely evacuating the facility with minimal assistance. Proceed to complete a com-
munity based assessment using the attached or a form which has received prior approval from the Section for Long Term
Care Regulation.
No Resident is not eligible for admission to an Assisted Living Facility.
INTERVIEWER NAME DATE
SAVE
Clear Form
MO 580-2835 (9-06) PAGE 2
PART II - RESIDENT ASSESSMENT (COMPLETED WITHIN 5 DAYS OF ADMISSION TO ASSISTED LIVING FACILITY)
RESIDENT NAME
RESPONDENT NAME
PERFORMS
INDEPENDENTLY
SOME
ASSISTANCE
TOTALLY
DEPENDENT
COMMENTS
PERSONAL CARE - Grooming/Bathing
Bathing
Dental/Mouth Care
Hair Care
Shaving
Toe/Fingernail Care
Bladder/Bowel Control Yes No
Special Equipment Required (List: )
Catheter/Ostomy Yes No
Eats Meals Daily
Meal Preparation
Chewing/Swallowing
Recent Weight Loss/Gain Yes No
Uses Feeding Tubes/Devices Calculated Diet Prescribed Yes No
Special Diet Followed Yes No
Ambulatory - Able to Get Around
Transfer To/From Bed
Transfer To/From Chair
Transfer To/From Wheelchair
Cleans Bedroom, Bathroom, Kitchen
Laundry
Make/Change Beds
Empty Trash
Safely evacuates the facility with minimal assistance.
PERSONAL CARE - Toileting
DIETARY
MOBILITY
HOUSEKEEPING
Yes No
MO 580-2835 (9-06) PAGE 3
WELL
ORIENTED
SOME MEMORY
LAPSE
NEEDS
ASSISTANCE
COMMENTS
BEHAVIOR/MENTAL CONDITION
TRANSPORTATION
MEDICAL NEEDS/SUPPORTS/MONITORING
Health Problems (Check All That Currently Apply) Prescription Meds Dosage Physician/Pharmacy
Orientation to Date, Day, and Place
Wanders or confusion
Memory/Recall
Judgment
Follows Instructions
Sociability
Sad or Anxious Mood Yes No
Socially Inappropriate/Disruptive Behavior Yes No
Diagnosed or Treatment History for Mental Illness or Developmental
Disability
Can drive self Yes No
Can leave the facility with assistance Yes No
Yes No
RESIDENT CAN
Self Administer Needs Assistance taking meds Totally dependent
Anemia
Arthritis and other joint limitations or injuries
Bowel/bladder problems
Cancer, Leukemia or tumor
Dementia (OBS, Alzheimer’s, Huntington’s, Pick’s)
Diabetes
Digestive disorders (ulcers, diverticulosis)
Edema
Effects of stroke (CVA, TIA, memory loss)
Effects of osteoporosis or fractures
Hardening of arteries (ASHD, poor circulation)
Hearing impairment (H.O.H., deafness)
Heart trouble (angina, CHF, MI)
Hypertension
Respiratory problems (asthma, emphysema, COPD)
Skin problems (decubitus ulcer, lesions, rashes)
Surgery with residual effects (drainage, amputation, paralysis,
pain, fatigue)
Tremors (Parkinson’s)
Visual impairment (cataracts, glaucoma, blindness)
NON PRESCRIPTION MEDICATIONS
OTHER (PLEASE LIST:)
MO 580-2835 (9-06) PAGE 4
List all physicians/clinics and other health providers.
State the condition for which the health provider is being seen, the frequency of contact, and describe what is being done (the procedure to
monitor the condition.
DOCTOR/CLINIC NAME
OTHER HEALTH CARE PROVIDER CONDITION FREQUENCY PROCEDURE
HOME HEALTH AGENCY NAME CONDITION FREQUENCY PROCEDURE
CONDITION FREQUENCY PROCEDURE
THIS ASSESSMENT FORM SHOULD BE USED TO DEVELOP THE INDIVIDUAL SERVICE PLAN FOR RESIDENT.
COMMENTS
INTERVIEWER NAME DATE
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PRE-SCREENING AND ASSESSMENT FOR ADMISSION TO ASSISTED LIVING (Missouri)

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Completed 21 May 2021

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