Individualized Service Plan requirements

Service Plan

Individualized Service Plan requirements

It’s funny how the real world relates to the world we operate inside of with our communities. Just as every person in the ‘natural’ world has specific likes, dislikes, and needs, our residents do just the same! Each person living in your facility has certain needs related to their personal care and must attended to as such. This is the reason behind why a ‘service plan’ is needed for each resident. We must assess each person and develop a plan for maintaining their care in order to provide the best possible experience for them. See the following regulation regarding service plans by the DC CRF/CRCFD/HRA:

10113 INDIVIDUALIZED SERVICE PLANS (ISPs)

10113.1 An ISP shall be developed for each resident not more than thirty (30) days prior to admission.

10113.2 An ALR shall support the involvement of family and friends selected by the resident to participate in the development, review, and renegotiation of his or her ISP under the Act and this chapter, provided that the involvement of the selected family and friends is conducive to the resident’s participation in the ISP development, review, or renegotiation. This subsection shall not apply to a resident’s surrogate acting in his or her capacity as the resident’s surrogate pursuant to law.

10113.3 An ALR shall ensure that the assessments conducted prior to a resident’s admission, pursuant to §§ 802 and 803 of the Act (D.C. Official Code §§ 44-108.02 and 44- 108.03), are performed by a registered nurse who is licensed to practice in the District, and any other healthcare professional necessary to perform the assessments as required who shall also be licensed or otherwise authorized to practice in the District.

10113.4 In accordance with § 604 of the Act (D.C. Official Code § 44-106.04), the ISP developed following the completion of the “post move-in” assessment shall be based on the following factors:

(a) The medical, rehabilitation, and psychosocial assessment of the resident, conducted by or on behalf of the ALR and in accordance with § 802 of the Act (D.C. Official Code § 44-108.02);

(b) The functional assessment of the resident, conducted by or on behalf of the ALR and in accordance with § 803 of the Act (D.C. Official Code § 44- 108.03); and

10113.5 A “post move-in” assessment required by § 604 of the Act (D.C. Official Code § 44-106.04) shall be conducted by or on behalf of the ALR within seventy-two (72) hours of a resident’s admission.

10113.6 An ALR shall ensure that the update of a resident’s ISP conducted pursuant to § 604(d) of the Act (D.C. Official Code § 44-106.04(d)) shall include the involvement of the following personnel on its behalf:

(a) A registered nurse licensed to practice in the District of Columbia;

(b) The ALA or Acting Administrator responsible for the ALR, if the health or safety of the resident is at risk; and

(c) Any additional healthcare professional licensed in the District whose expertise is necessary for the ALR to perform a full and competent review of the services provided in the ISP prior.

10113.7 At or around the time of an ISP review conducted pursuant to § 604(d) of the Act (D.C. Official Code § 44-106.04(d)), the ALR shall:

(a) Obtain from the resident (or surrogate) a signed statement confirming that the resident (or surrogate):

(1) Was invited to participate in the review of the ISP; and

(2) Did or did not participate in the review of the ISP; or,

(b) If the resident has refused to give signed confirmation regarding the same ISP review on two (2) separate occasions, document in the resident’s record the date, time, and method of each attempt to obtain the resident’s signed confirmations and the name of the ALR personnel who made each attempt.

10113.8 An ALR shall provide the resident (or surrogate) no less than seven (7) days’ notice prior to the review of a resident’s ISP conducted pursuant to § 604(d) of the Act (D.C. Official Code § 44-106.04(d)), unless seven days’ (7) notice is made impractical due to a significant change in the resident’s condition that necessitates review of the resident’s ISP at a sooner date. The notice shall:

(a) Include the date, time, and location at which the ALR proposes to conduct the ISP review, and advise the resident (or surrogate) that he or she may request to reschedule the ISP review to another date or time that is mutually agreeable;

(b) Include an outline of the topics to be discussed during the ISP review and no less than a summary of the ALR’s proposed changes to the ISP, if any, in order to facilitate the resident’s (or surrogate’s) informed decision-making;

(c) Encourage the resident (or surrogate) to participate in the ISP review with the involvement of family and friends of the resident’s choice in accordance with § 10113.2; 17

(d) Be delivered to the resident (or surrogate) in writing; and

(e) Be followed by no less than one (1) written reminder encouraging the resident (or surrogate) to participate in the review.

10113.9 An ALR shall permit a resident (or surrogate) to reschedule the review of his or her ISP conducted pursuant to § 604(d) of the Act (D.C. Official Code § 44-106.04(d)) to a date and time that is mutually agreeable.

10113.10 If a resident (or surrogate) disagrees with an ISP that is updated pursuant to § 604(d) of the Act (D.C. Official Code § 44-106.04(d)), the ALR shall:

(a) Attempt to resolve the disagreement according to its written policy and procedure for addressing a resident’s disagreement with his or her updated ISP, which shall be implemented consistent with this subsection and in accordance with all applicable provisions of the Act and this chapter;

(b) Indicate within the ISP the portions that are in dispute;

(d) Record in the resident’s record the date, time, and summary of each effort by the parties to discuss and resolve the disputed portions of the ISP, including, if applicable, the resident’s (or surrogate’s) uncoerced, written, informed consent to implement the portions of the ISP that are not in dispute, pursuant to §§ 10113.11 and 10113.12; and

(e) If attempts to resolve the dispute pursuant to paragraph (a) are unsuccessful, attempt to negotiate a shared responsibility agreement (“SRA”) with the resident (or surrogate) according to the ALR’s written policy and procedures, which shall be in accordance with § 605 of the Act (D.C. Official Code § 44-106.05) and § 10114 of this chapter.

10113.11 A resident’s (or surrogate’s) disagreement with an ISP that is updated pursuant to § 604(d) of the Act (D.C. Official Code § 44-106.04(d)) and in accordance with the Act and this chapter shall not, in and of itself, prevent the ALR from attempting to implement the ISP, provided that the individuals charged with implementing the ISP do not administer medications or treatments to the resident’s person without the resident’s (or surrogate’s) consent. This subsection shall not be construed to prevent a resident (or surrogate) from engaging in negotiations to reach a SRA in accordance with § 605 of the Act (D.C. Official Code § 44-106.05) and § 10114 of this chapter, for reasons including, but not limited to, resolving a disagreement with respect to that resident’s ISP, or exercising that resident’s right to refuse participation in a service as provided by § 504(5) of the Act (D.C. Official Code § 44-105.04(5)).

10113.12 Consistent with § 10113.11, an ALR shall be permitted to implement an ISP that has been disputed by the resident (or surrogate) as follows:

(a) Implementation is limited to the portions of the ISP that are not in dispute, and in accordance with the resident’s (or surrogate’s) uncoerced, written, informed consent. For the purposes of this paragraph, informed consent requires that, prior to giving consent, the resident (or surrogate) has been provided, in writing, the specific ISP services that will not be implemented at that time, and an opportunity to have the ALR explain the consequences of accepting and forgoing the disputed portions of the ISP;

(b) Implementation is in accordance with an SRA that has been reached in order to resolve the resident’s (or surrogate’s) disagreement with the ISP, pursuant to the ALR’s written policy and procedures and in accordance with the Act and § 10114 of this chapter; or

(c) Implementation of a disputed portion of the ISP is necessitated by a health emergency or by the resident’s urgent medical needs as explicitly delineated in the signed, written orders of an attending healthcare practitioner or registered nurse.

10113.13 The ALR shall periodically monitor a resident who foregoes an ISP service in order to ascertain whether the resident can continue to forego the service safely.

10113.14 Nothing in this section shall compel an ALR to enter into a SRA that is inconsistent with § 605 of the Act (D.C. Official Code § 44-106.05), § 10114 of this chapter, or other applicable District or federal requirement.

Top Takeaways:

2 An ALR shall support the involvement of family and friends selected by the resident to participate in the development, review, and renegotiation of his or her ISP under the Act and this chapter, provided that the involvement of the selected family and friends is conducive to the resident’s participation in the ISP development, review, or renegotiation.

Family involvement is key to developing an effective ISP. The resident’s family was often the caregiver prior to moving into the ALF which gives them tremendous insight into the day to day needs of the resident.

3 An ALR shall ensure that the assessments conducted prior to a resident’s admission, pursuant to §§ 802 and 803 of the Act (D.C. Official Code §§ 44-108.02 and 44- 108.03), are performed by a registered nurse who is licensed to practice in the District, and any other healthcare professional necessary to perform the assessments as required who shall also be licensed or otherwise authorized to practice in the District.

CRF/CRCFD/HRA mandates that an RN or licensed medical professional shall conduct the pre admission assessment along with a ‘post move-in assessment’ at the most 72 hours post admission. The assessment is one of the most important elements the ISP as the information received in this interview helps build the services and care required for each resident.