Before anyone moves into a Georgia personal care home, a licensed clinician has to complete the state’s Physician’s Medical Evaluation for Assisted Living form. A physician, physician assistant, or nurse practitioner performs a physical exam, documents diagnoses, medications, and the resident’s ability to handle daily activities, and signs a certification that the person’s needs can be safely met in a personal care home. The exam has to happen within the 30 days before the admission date, so the first move is booking the appointment early enough that there’s room to fix anything incomplete.
Getting the Form
The official form is titled “Physician’s Medical Evaluation for Assisted Living” and downloads as a PDF from the Department of Community Health Licensure Forms and Applications page at dch.georgia.gov.1Georgia Department of Community Health. Licensure Forms and Applications Most personal care home admissions offices keep blank copies and will hand one to the family. Print it before the appointment. A general practitioner’s office will not necessarily have a Georgia-specific form on file.
Who Signs It and When
Three types of licensed professionals can perform the exam and sign the form: a physician (MD or DO), a physician assistant, or a nurse practitioner.2Georgia Health. Physicians Medical Evaluation for Assisted Living The signature block at the bottom needs the clinician’s Georgia license number, printed name, signature, and office address. Illegible or missing credentials are a frequent reason forms get kicked back during a facility review.
The exam has to take place within 30 days before admission so the clinical picture stays current.3U.S. Department of Health and Human Services. Compendium of Residential Care and Assisted Living Regulations and Policy 2015 Edition If you have the luxury of planning, schedule the visit two weeks or so ahead of the move-in date. That leaves time for follow-up labs, a corrected signature page, or a TB test result that has not come back yet.
Emergency admissions work differently. When adult protective services, local law enforcement, or a case manager requests an emergency placement, the home may admit the resident without the completed form and obtain the physical examination within 14 days after admission.4Georgia Secretary of State. Georgia Administrative Code 111-8-62 – Personal Care Homes The home has to keep documentation showing why the placement qualified as an emergency.
Working Through the Form Section by Section
Bring a current medication list, a list of allergies, and any recent hospital discharge paperwork to the appointment. The clinician works through the form during or right after the exam, and having the background in hand cuts the visit down considerably.
Patient Information and Diagnoses
The top of the form collects name, date of birth, height, weight, address, and phone number. A checkbox marks the reason for the evaluation: pre-admission, annual update, possible change in condition, or other. For a first-time admission, check Pre-Admission. The clinician then lists all current medical diagnoses along with any physical or mental health limitations.2Georgia Health. Physicians Medical Evaluation for Assisted Living
Activities of Daily Living
Section 8 rates the resident’s ability to perform everyday tasks. Each activity receives a rating along the lines of “Independent,” “Needs supervision,” “Needs assistance,” or “Needs total help.” The assessed activities include:
- Ambulating, from independent walking to bedridden.
- Bathing, dressing, and grooming.
- Eating, including whether tube feeding is needed.
- Toileting.
- Transferring between positions, such as bed to chair.
- Skin integrity, including any pressure sores and their stage, and any need for adult briefs, catheter care, or ostomy care.
These ratings control whether admission is even legal. Georgia regulations require personal care home residents to be ambulatory and capable of self-preservation with minimal assistance, meaning staff may help a resident transfer from a sitting or reclining position and give verbal directions, but the resident must be able to move to the nearest exit on their own.4Georgia Secretary of State. Georgia Administrative Code 111-8-62 – Personal Care Homes Someone who is bedridden or requires total help ambulating generally cannot be placed in a standard personal care home.
Clinical Statements
Section 9 asks five yes-or-no clinical questions, and the answers determine whether the resident qualifies:
- TB screening. The clinician confirms whether the person has been screened for tuberculosis and whether they show signs or symptoms of any infectious disease likely to spread. The form has space for the screening date and results.2Georgia Health. Physicians Medical Evaluation for Assisted Living
- Whether the individual’s behavior poses a danger to self or others.
- Whether the resident needs staff assistance overnight.
- Whether the individual requires 24-hour nursing supervision. A yes here disqualifies admission to a personal care home.
- Whether the person needs a specialized memory care unit with controlled access designed for residents at risk of unsafe wandering.
The TB screening question does not require a specific method. A PPD skin test, an IGRA blood test, or a chest X-ray can all serve, depending on medical history. If the person has had a positive skin test previously, the clinician should document the follow-up results. Older adults sometimes produce unreliable skin test results, so it is worth asking the clinician which method fits the resident.
Medications
Section 10 requires every medication the resident takes: prescriptions, over-the-counter drugs, herbal remedies, topical treatments, and vitamins. For each one, the clinician records the name, dosage, directions for use, and route of administration. A separate column asks whether the resident needs help with each medication, yes or no.2Georgia Health. Physicians Medical Evaluation for Assisted Living An up-to-date pharmacy printout saves the clinician from reconstructing the list.
Diet, Allergies, and Supportive Services
Separate sections record dietary instructions (regular, no added table salt, no concentrated sweets, or something more specific), known allergies, and any supportive services the resident currently uses. Be specific. “Low sodium” tells the facility more than “special diet.” The clinician also notes any ongoing treatments or therapies.
Medical Certification
At the bottom, the clinician signs a certification stating that, in their professional opinion, the resident’s needs can be safely met in a personal care home. The form itself reminds the clinician that personal care homes are not permitted to provide medical, skilled nursing, or psychiatric care.2Georgia Health. Physicians Medical Evaluation for Assisted Living A “No” here means the resident needs placement in a higher-level facility such as a skilled nursing home, which provides 24-hour medical oversight for chronic conditions, post-surgery recovery, or advanced care such as IV therapy or wound management.
Answers That Will Keep the Resident Out
Georgia regulations prohibit a personal care home from admitting or keeping a resident who:
- Requires continuous medical or nursing care and services.
- Requires the use of physical or chemical restraints, isolation, or confinement for behavioral control.
- Needs care beyond what the home is licensed to provide.
Medical, nursing, or therapeutic services needed on a periodic basis, such as physical therapy or wound care from a visiting nurse, have to be purchased separately from an outside licensed provider. The personal care home cannot supply them directly.4Georgia Secretary of State. Georgia Administrative Code 111-8-62 – Personal Care Homes The home can help arrange those services, but delivering them falls outside its license.
After the Form Is Signed
Deliver the signed original to the personal care home administrator. The administrator reviews it to confirm the resident does not require a higher level of care than the facility is licensed to provide, and the form then becomes part of the resident’s permanent file.
The medical evaluation is not a one-time document. The form lists “Annual” as a reason for evaluation, and facilities should arrange a new physical on the same form at least once a year to keep the resident’s medical profile current.2Georgia Health. Physicians Medical Evaluation for Assisted Living If a resident experiences a significant change in physical or mental condition, the home must be able to produce a current physical examination report from a physician, nurse practitioner, or physician assistant on request from the Department of Community Health, confirming the resident still meets the retention requirements.4Georgia Secretary of State. Georgia Administrative Code 111-8-62 – Personal Care Homes A stroke, a new dementia diagnosis, or a serious fall are the kinds of events that can trigger a fresh evaluation.