The resident service plan

The resident’s 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 Massachusetts Executive Office of Elder Affairs:

(7) Service Plan Development.

The nurse and Service Coordinator shall develop an individualized Service Plan for each Resident in accordance with the findings of the initial screening described in 651 CMR 12.04(6). Said service plan shall be developed before the Resident moves into the Residence and be based on information provided by the Resident, his or her Legal Representative or Resident Representative. The Residence shall ensure the Resident’s participation in the development of the service plan to the maximum extent possible and shall include the Legal Representative or Resident Representative to the extent that he or she is authorized, willing and able to be involved. The service plan shall include an evaluation, conducted within the past three months by the Resident’s physician or authorized practitioner, of the prospective Resident’s physical, cognitive, functional, and psychosocial condition. It is the responsibility of the Resident or his or her representative to have the physician’s or authorized practitioner’s evaluation completed. In addition:

(a) The Residence shall, at a minimum, document its assessment findings for the Resident on the following:

  1. Allergies;
  2. Diagnoses;
  3. Medications (including dosage, method of administration and frequency);
  4. Dietary needs;
  5. Need for assistance in emergency situations;
  6. History of psychosocial issues including the presence of manifestations of distress, or behaviors which may present a risk to the health and safety of the Resident or others;
  7. Level of personal care needs, including ability to perform ADLs and IADLs; and
  8. Ability of the Resident to manage medication, including the ability to take medication on an as-needed basis.

(b) The Service Coordinator or nurse shall review the Resident’s initial service plan within 30 days of the commencement of residency and document the review to ensure the Resident’s needs and preferences are accurately incorporated therein and that the Residence is capable of meeting the Resident’s needs in accordance with 651 CMR 12.00. The initial service plan shall be in writing, signed and dated by the Resident or his or her Legal Representative, and by the Sponsor or his or her representative.

(8) Service Plan Requirements.

(a) Each service plan shall be based on a current assessment of the Resident, and indicate the following:

  1. The services needed, including the minimum service package provided for a monthly fee and any additional services the Resident needs;
  2. The Resident’s goals, and the frequency and duration of all services provided to address the Resident’s particular physical, cognitive, psychological and social needs, including but not limited to the following:
  3. Details of the manner in which the Residence shall provide for the presence of a 24 hour per day, on site staff, and the manner in which the Residence shall provide for personal emergency response devices or procedures;
  4. Details of the types of assistance with medications that the Residence shall provide, if any;
  5. Description of services that will be provided by a person or entity not affiliated with the Assisted Living Residence or by a certified provider of ancillary health services (e.g. VNA services, private duty aides, adult day care) if the Resident, Resident Representative, or Legal Representative notifies the Assisted Living Residence that he or she has arranged for such services; and
  6. The need for a meal plan prescribed or ordered by a Resident’s physician. The Residence shall have a qualified dietitian review the Resident’s dietary needs, and provide the Resident with diet management counseling; and
  7. The service plans for Residents residing in Special Care Units must indicate the enrichment activities provided to them as set forth in 651 CMR 12.04(4).

(b) All service plans shall be in writing, signed and dated by the Resident or his or her Legal Representative, and by the Sponsor or his or her representative.

(c) Following the Service Plan reassessment required by 651 CMR 12.04(7)(b), the Service Coordinator or nurse shall review the Service Plan not less than every six months, or at any time upon identifying an improvement in the Resident’s condition or a decline in a Resident’s condition that will not normally resolve itself without intervention by staff, is not self-limiting, impacts more than one area of the Resident’s health status, and requires interdisciplinary review and/or revision of the Service Plan. The Service Coordinator or nurse shall document the Service Plan review to ensure the Resident’s needs and preferences are accurately incorporated therein and that the Residence is capable of meeting the Resident’s needs in accordance with 651 CMR 12.00. The service plan shall be confidential except to the extent necessary to provide services and manage the operations of the Assisted Living Residence; provided that EOEA may review the service plan at any time with the consent of the Resident or his or her Legal Representative

Top Takeaways:

  • The Residence shall ensure the Resident’s participation in the development of the service plan to the maximum extent possible and shall include the Legal Representative or Resident Representative to the extent that he or she is authorized, willing and able to be involved.

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

  • (b) The Service Coordinator or nurse shall review the Resident’s initial service plan within 30 days of the commencement of residency and document the review to ensure the Resident’s needs and preferences are accurately incorporated therein and that the Residence is capable of meeting the Resident’s needs in accordance with 651 CMR 12.00. The initial service plan shall be in writing, signed and dated by the Resident or his or her Legal Representative, and by the Sponsor or his or her representative.

The initial service plan is a document that the facility must use to build upon and tweak to meet the present day needs of each resident. The ALR must go back and review the ISP within 30 days of the resident admitting to the community to ensure they have an accurate depiction of the residents needs.

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