When developing a resident’s care plan, you should take all aspects of the resident assessment, physical examination, and interview into consideration. This valuable information is key to providing the resident with the right care at the right time. Residents need to be aware of what services they are scheduled for and the frequency in which you plan to perform them. Check out the following regulation for how you can stay compliant with the ADPH and what they expect for the personal care of a resident:
420-5-4-.06 Care of Residents
(4) Personal Care and Services.
The facility shall provide care and services consistent with community standards.
(a) Portions of residents’ records necessary for staff to provide care, including the plans of care and relevant portions of the medical examination records and admission records, shall be accessible to the direct care staff at all times.
(b) Plan of Care. There shall be a written plan of care developed for each resident prior to or at the time of admission. The plan of care shall be based on the initial medical examination, diagnoses, and recommendations of the resident’s treating physician. The plan of care shall be reviewed and updated based on the annual examination, and all other physician examinations, diagnoses, and recommendations of the resident’s treating physician, and the resident’s monthly assessments. The plan of care shall be developed and updated in cooperation with the resident and, if appropriate, the sponsor. All entries on the plan of care shall be accurately dated.
- The plan shall at all times reflect the current condition of the resident and document the personal care and services required from the facility by the resident. In addition to other items that may be required by the facility’s own policies and procedures, the plan of care shall contain the following:
- A listing of the resident’s individual needs or problems that require intervention by the facility.
- A listing of interventions provided by the facility to address the resident’s identified needs or problems.
- A copy of any outside provider’s certification and plans of care, such as the current Home Health Certification and Plan of Care for each resident receiving care from an outside provider.
- Activities of Daily Living. Residents of assisted living facilities shall be assisted and encouraged to maintain a clean, well-kept personal appearance. Each facility shall provide all needed assistance with activities of daily living to each resident.
(i) Bathing. Residents shall be offered a bath or partial bath or shall be assisted with a bath or partial bath daily, and more often when necessary or requested.
(ii) Oral Hygiene. Residents shall be assisted with oral hygiene to keep mouth, teeth, or dentures clean. Measures shall be used to prevent dry, cracked lips.
(iii) Hair. The Resident’s hair shall be kept clean, neat, and well-groomed.
(iv) Manicure. Fingernails and toenails shall be kept clean and trimmed.
(v) Shaving. Men shall be assisted with shaving or shaved as necessary to keep them clean and well-groomed.
(vi) Personal Safety. Residents shall be provided assistance with personal safety.
- As changes in medication and personal services become necessary, the plan of care shall be promptly updated and all changes shall be documented.
(c) The facility shall offer appropriate activity programs to each resident, maintaining supplies and equipment as necessary to implement the activity programs. Every day the facility shall provide activities appropriate to each resident.
(d) Pets residing at the facility or used in activity programs shall be in good health and shall have current vaccinations as required by law. Vaccination certificates, or copies of vaccination certificates, shall be kept on file at the facility to demonstrate compliance with this requirement.
(e) Mail, Telegrams, and Other Communications.
- Incoming mail, telegrams, and other written communications addressed to the resident shall be delivered to the resident unopened. Outgoing mail shall be promptly delivered to regular postal channels upon receipt from the resident. Residents shall be permitted to place and receive telephone calls at the facility in complete privacy.
- Personnel of the facility shall assist residents with communications, such as writing letters or assisting with writing letters, or reading mail out loud if requested to do so.
(f) Appointments. Residents shall be assisted in making and keeping appointments.