.28 Service Plan.

A. Service Plan Development.

(1) 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.

(2) 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.

(3) The resident shall be invited to participate in the development of the initial service plan and any subsequent service plans.

(4) At the resident’s request, a resident representative, family member, or other individual shall be invited to participate in all service plan meetings.

(5) When the resident lacks the capacity to participate, the resident representative, as applicable to their authority, shall be invited to participate in all service plan meetings.

(6) The assisted living program shall accommodate the schedules of participants in a service plan meeting when possible.

B. Assessment of Condition.

(1) The resident’s service plan shall be based on an assessment of the resident’s health, function, behavioral, and psychosocial status using the Resident Assessment Tool and the nursing assessment.

(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 awake overnight staff is required due to a change in the resident’s condition.

C. Special Care Needs. The service plan shall reflect increased monitoring, intervention, and oversight, as clinically appropriate for special care needs, including:

(1) Fall risk or frequent falls;

(2) Pressure ulcer risk, prevention, and treatment;

(3) Diabetes management;

(4) Oxygen therapy;

(5) Enteral feedings;

(6) Foley catheter care;

(7) Ostomy care;

(8) Therapeutic medication levels;

(9) Mental illness; and

(10) Behaviors that are likely to disrupt or harm the resident or others.

D. 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 addresses:

(a) The services to be provided to the resident, which are 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 calendar 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.