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LIC 9172: Functional Capability Assessment

By Sevana Care · Checked against cdss.ca.gov and Title 22 on

When it is due
The form sets no date for RCFEs [1].Section 87457(c) requires a suitability determination before admission, and its appraisal must document the prospective resident's functional capabilities [4]. The appraisal must be "updated in writing as frequently as necessary or once every 12 months, whichever occurs first" [5].
Who fills it out
The facility assesses the person's ability to perform activities of daily living [2].The licensee or the employee responsible for admissions interviews the prospective resident and the responsible person, if any, before admission [4]. The form has two signature lines, each with a "date completed": the applicant or authorized representative, and the licensee or facility representative [1].
Where it is kept
Section 87506(a) requires a record for each resident, in the facility or at a central administrative location readily available to licensing staff, and item (b)(17)(B) puts "documents and information required by" § 87459 in that record [6].CDSS's list of records an RCFE keeps (LIC 311F, 4/05) does not name LIC 9172 [8].
How long to keep
Section 87506(e) sets a minimum of three years after service to the resident ends for original records [6].Section 87506 does not name LIC 9172 [6].

LIC 9172 is the California Department of Social Services (CDSS) Functional Capability Assessment, a two-page checklist of what a person can do for themselves, such as bathing, dressing, eating and walking [1]. Its note says RCFEs "may use this form to assess the person's functional capabilities as required in Section 87584" [1]. That section number is out of date: § 87584 was renumbered § 87459 in 2008 [3][2]. Section 87459 requires the home to assess a person's ability to do listed daily activities and names no form [2].

Who fills it out

Section 87459(a): "The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living" [2]. Before admission, the licensee or the employee responsible for admissions interviews the prospective resident and the responsible person, if any [4].

The form has two signature lines, each with a "date completed" [1]:

  • the applicant or authorized representative
  • the licensee or facility representative

The prospective resident, or the responsible person, takes part in developing the appraisal [4].

When it is due

The form sets no date for RCFEs. Its header says licensees of Adult Residential and Social Rehabilitation Facilities "must obtain the following information prior to placement." It says RCFEs "may use this form" [1].

The rule ties functional capabilities to the appraisal before admission. Section 87457(c) requires a suitability determination before admission, and its appraisal must document "an evaluation of the prospective resident's functional capabilities, mental condition, and social factors as specified in Sections 87459 ... and 87462" [4].

Updates. The appraisal must be "updated in writing as frequently as necessary or once every 12 months, whichever occurs first," and the update "shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition" [5].

Where it is kept

Section 87506(a) requires a record for each resident, in the facility or at a central administrative location readily available to licensing staff. Item (b)(17)(B) puts "documents and information required by" § 87459 in that record [6]. Section 87505 requires the findings of the appraisal and any reappraisal to be documented in writing [7].

How long to keep it. Section 87506(e): "Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident" [6]. Section 87506 does not name LIC 9172 [6].

What the record must show

What § 87459(a) lists. The home assesses the ability to do activities that include at least these, with the kind of help needed [2]:

  • bathing
  • dressing and grooming
  • toileting
  • transferring in and out of a bed or chair
  • continence, including whether a device such as a catheter is used
  • eating
  • physical condition: vision, hearing, speech, walking, dietary limitations, medical history and problems, and need for prescribed medications

What the form asks. Check boxes for bathing, dressing, toileting, transferring, continence, eating, grooming, repositioning, wheelchair use, vision, hearing, communication and walking [1]. Then it asks for medical history and conditions, prescription and non-prescription medicine, mental and emotional status, history of behavior that harms self or others, and ability to manage money [1].

What the form leaves out. The rule asks about "Dietary limitations," about "Adaptive devices" for eating, about bathing "Through use of grab bars," and about toileting "Assistance equipment" [2]. The form has no box or field for these [1].

Questions

Does an RCFE have to use LIC 9172?

The form says RCFEs "may use" it [1]. Section 87459 sets the assessment and names no form [2], and CDSS's RCFE records list does not name LIC 9172 [8].

Why does the form say Section 87584?

The form is dated 8/01 [1]. The history line for § 87459 reads "renumbering former section 87584 to section 87459 ... filed 3-5-2008," and the Westlaw page for § 87584 is headed "Functional Capabilities. [Renumbered]" [2][3]. Section 87459 carries the heading "Functional Capabilities" [2].

Is LIC 9172 the same as the resident appraisal, LIC 603A?

No. They are separate CDSS forms [9][10]. LIC 603A has its own "Functional Capabilities" and "Services Needed" sections [9]. None of the cited sources says one replaces the other.

More in Admission and the resident file

  • LIC 604A: The CDSS guide for the admission agreement you sign with each resident
  • LIC 613C-2: The personal rights a resident signs at admission
  • LIC 601: The form with a resident's contacts, doctor, hospital and emergency details
  • LIC 627C: The signed consent for emergency medical or dental care
  • PUB 325: The brochure on medical care decisions that you give each resident on admission

Sources

  1. CDSS, LIC 9172 (8/01), Functional Capability Assessment (PDF)
  2. California Code of Regulations, Title 22, § 87459, Functional Capabilities (Westlaw)
  3. California Code of Regulations, Title 22, § 87584, Functional Capabilities [Renumbered] (Westlaw)
  4. California Code of Regulations, Title 22, § 87457, Pre-Admission Appraisal (Westlaw)
  5. California Code of Regulations, Title 22, § 87463, Reappraisals (Westlaw)
  6. California Code of Regulations, Title 22, § 87506, Resident Records (Westlaw)
  7. California Code of Regulations, Title 22, § 87505, Documentation and Support (Westlaw)
  8. CDSS, LIC 311F (4/05), Records To Be Maintained At The Facility, Residential Care Facility For The Elderly (PDF)
  9. CDSS, LIC 603A (7/99), Resident Appraisal, Residential Care Facilities for the Elderly (PDF)
  10. CDSS, Forms and Publications (I-L)