Section 430. Uniform assessment instrument (UAI)

Part VI. Resident Care and Related Services

A. All residents of and applicants to assisted living facilities shall be assessed face-to-face using the uniform assessment instrument pursuant to the requirements in Assessment in Assisted Living Facilities (22VAC40-745). Assessments shall be completed prior to admission, annually, and whenever there is a significant change in the resident's condition.

1. For private pay individuals, the UAI shall be completed by one of the following qualified assessors:

a. An assisted living facility staff person who has successfully completed state-approved training on the uniform assessment instrument and level of care criteria for either public or private pay assessments, provided the administrator or the administrator's designated representative approves and then signs the completed UAI, and the facility maintains documentation of the completed training;

EXCEPTION: An assisted living facility staff person who began employment at the facility prior to December 28, 2006, and who had documented training that was not state approved in the completion of the UAI and application of level of care criteria shall meet the requirements for state-approved training within one year from December 28, 2006;

b. An independent physician; or

c. A qualified public human services agency assessor.

2. For public pay individuals, the UAI shall be completed by a case manager or qualified assessor as specified in 22VAC40-745.

B. The UAI shall be completed within 90 days prior to the date of admission to the assisted living facility except that if there has been a change in the resident's condition since the completion of the UAI that would affect the admission, a new UAI shall be completed.

C. When a resident moves to an assisted living facility from another assisted living facility or other long-term care setting that uses the UAI, if there is a completed UAI on record, another UAI does not have to be completed except that a new UAI shall be completed whenever:

1. There is a significant change in the resident's condition; or

2. The previous assessment is more than 12 months old.

D. The assessor is responsible for being knowledgeable of the criteria for level of care and authorizing the individual for the appropriate level of care for admission to and for continued stay in an assisted living facility based on the information in the UAI.

E. Annual reassessments and reassessments due to a significant change in the resident's condition, using the UAI, shall be utilized to determine whether a resident's needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident.

F. For private pay individuals, the assisted living facility shall ensure that the uniform assessment instrument is completed as required by 22VAC40-745.

G. For a private pay resident, if the UAI is completed by an independent physician or a qualified human services agency assessor, the assisted living facility shall be responsible for coordinating with the physician or the agency assessor to ensure that the UAI is completed as required.

H. The assisted living facility shall be in compliance with all requirements set forth in 22VAC40-745.

I. The facility shall maintain the completed UAI in the resident's record.

J. At the request of the assisted living facility, the resident, the resident's legal representative, the resident's physician, the department, or the local department of social services, an independent assessment using the UAI shall be completed to determine whether the resident's care needs are being met in the assisted living facility. The assisted living facility shall assist the resident in obtaining the independent assessment as requested.

An independent assessment is one that is completed by a qualified entity other than the original assessor.

K. During an inspection or review, staff from the department, the Department of Medical Assistance Services, or the local department of social services may initiate a change in level of care for any assisted living facility resident for whom it is determined that the resident's UAI is not reflective of the resident's current status.

L. The facility shall ensure that facility staff and independent physicians who are qualified assessors advise orally and in writing all applicants to and residents of assisted living facilities of the right to appeal the outcome of the assessment, the annual reassessment, or determination of level of care.

Historical Notes

Derived from Volume 23, Issue 06, eff. December 28, 2006; amended, Virginia Register Volume 25, Issue 08, eff. February 5, 2009.

Statutory Authority

§§ 63.2-217 and 63.2-1732 of the Code of Virginia.