481—57.22(135C) Service plan.
57.22(1) Prior to admission of a resident, the administrator or the administrator’s designee shall
develop a written and organized orientation plan. The plan shall be designed to assist the resident in
adapting to the facility and to assist the facility staff in becoming knowledgeable of the resident and the
resident’s needs. (III)
57.22(2) Within 30 days of admission, the administrator or the administrator’s designee shall, in
conjunction with the resident, other facility staff or any organization that works with or serves the
resident, develop a written, individualized, and integrated program of ongoing services for the resident.(III)
a. The program shall be planned and implemented to address the resident’s priorities and assessed
needs, such as living, rehabilitation, activity, behavioral, emotional, mental health and social, and shall
take into consideration the resident’s personal goals and preferences, including the resident’s preferred
living situation. (III)
b. The service plan shall include specific goals and objectives with regular documentation of each.(III)
c. The service plan shall be reviewed at least quarterly, or more often as necessary. (III)
57.22(3) Communicationsrelated to service plan changes or changesin the resident’s condition shall
occur within five working days of the change, and shall be conveyed to all individuals inside and outside
the residential care facility who work with the resident, as well as to the resident’s family members or
responsible party. (III)