INDIVIDUAL SERVICE PLAN (ISP):  An ISP shall be developed and implemented within ten (10) calendar days of admission for each resident residing in the facility.

  1.             The ISP shall address those areas of need as identified in the resident evaluation and through staff observation.

                                (1)           The ISP shall detail the services that are provided by the facility as well as the services to be provided by other agencies.

                                (2)           The resident evaluation and the ISP shall be reviewed and if needed to be revised by a licensed practical nurse, registered nurse or a physician extender.

                                (3)           The ISP shall be reviewed and or revised at a minimum of every six (6) months or when there is a significant change in the resident’s health status.

  1.             The ISP shall include the following:

                                (1)           a description of identified needs as noted in the resident evaluation;

                                (2)           a written description of all services to be provided;

                                (3)           who will provide the services;

                                (4)           when or how often the services will be provided;

                                (5)           how the services will be provided;

                                (6)           where the services will be provided;

                                (7)           expected goals and outcomes of the services;

                                (8)           documentation of the facility’s determination that it is able to meet the needs of the resident;

                                (9)           the level of assistance that the resident will require with activities of daily living and with medications;

                                (10)         a crisis prevention/intervention plan when indicated by diagnosis or behavior; and

                                (11)         current orders for all medications, including those authorized for PRN usage.

[ NMAC – Rp, NMAC, 1/15/2010]