Service Plan

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 Maryland Office of Health Care

.26 Service Plan.

A. The assisted living manager, or designee, shall ensure that all services are provided in a manner that respects
and enhances the dignity, privacy, and independence of each resident. A service plan for each resident shall be
developed in a manner that enhances the principles of dignity, privacy, resident choice, resident capabilities,
individuality, and independence without compromising the health or reasonable safety of other residents.
B. Assessment of Condition.
(1) The resident’s service plan shall be based on assessments of the resident’s health, function, and psychosocial
status using the Resident Assessment Tool.
(2) A full assessment of the resident shall be completed:
(a) Within 48 hours but not later than required by nursing practice and the patient’s condition after:
(i) A significant change of condition; and
(ii) Each nonroutine hospitalization; and
(b) At least annually.
(3) When the delegating nurse determines in the nurse’s clinical judgment that the resident does not require a
full assessment within 48 hours, the delegating nurse shall:
(a) Document the determination and the reasons for the determination in the resident’s record; and
(b) Ensure that a full assessment of the resident is conducted within 7 calendar days.
(4) A review of the assessment shall be conducted every 6 months for residents who do not have a change in
condition. Further evaluation by a health care practitioner is required and changes shall be made to the resident’s
service plan if there is a score change in any of the following areas:
(a) Cognitive and behavioral status;
(b) Ability to self-administer medications; and(c) Behaviors and communication.
(5) If the resident’s previous assessment did not indicate the need for awake overnight staff, each full
assessment or review of the full assessment shall include documentation as to whether the awake overnight staff is
required due to a change in the resident’s condition.
C. The assisted living manager, or designee, shall ensure that:
(1) A written service plan or other documentation sufficiently recorded in the resident’s record is developed by
staff, which at a minimum address:
(a) The services to be provided to the resident, which is based on the assessment of the resident;
(b) When and how often the services are to be provided; and
(c) How and by whom the services are to be provided;
(2) The service plan is developed within 30 days of admission to the assisted living program; and
(3) The service plan is reviewed by staff at least every 6 months and updated, if needed, unless a resident’s
condition or preferences significantly change, in which case the assisted living manager or designee shall review and
update the service plan sooner to respond to these changes.

Pro Tip:
• Create an environment where all staff members ‘buy-in’ to the constant revision of service plans
by communicating the ever-changing needs of the resident. So many people come in contact
with a resident throughout the day and notice new needs or a change in condition but think
nothing of communicating that to the care team.