Section 440. Individualized service plans

A. The licensee/administrator who has completed an individualized service plan (ISP) training program approved by the department or his designee who has completed such a program shall develop an individualized service plan to meet the resident's service needs. The licensee/administrator or designee shall develop the ISP in conjunction with the resident, and as appropriate, with the resident's family, legal representative, direct care staff members, case manager, health care providers, qualified mental health professionals, or other persons. The plan shall be designed to maximize the resident's level of functional ability.

An individualized service plan is not required for those residents who are assessed as capable of maintaining themselves in an independent living status.

B. The service plan to address the immediate needs of the resident shall be completed within 72 hours of admission. The comprehensive plan shall be completed within 30 days after admission and shall include the following:

1. Description of identified needs based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) assessment of psychological, behavioral and emotional functioning, if appropriate; and (v) other sources;

2. A written description of what services will be provided and who will provide them;

3. When and where the services will be provided;

4. The expected outcome and date of expected outcome; and

5. If a resident lives in a building housing 19 or fewer residents, a statement that specifies whether the person does need or does not need to have a staff member awake and on duty at night.

C. The individualized service plan shall reflect the resident's assessed needs and support the principles of individuality, personal dignity, freedom of choice and home-like environment and shall include other formal and informal supports that may participate in the delivery of services. Whenever possible, residents shall be given a choice of options regarding the type and delivery of services.

D. When hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate, establish and agree upon a coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan.

E. The individualized service plan shall be signed and dated by the licensee/administrator or his designee, i.e., the person who has developed the plan, and by the resident or his legal representative. The plan shall also be signed and dated by any other individuals who contributed to the development of the plan. Each person signing the plan shall note his title or relationship to the resident next to his signature. These requirements shall also apply to reviews and updates of the plan.

EXCEPTION: The signature of an individual who contributed to the plan without being present at the facility shall not be required, although his name, date of participation, and title or relationship shall be indicated on the plan.

F. The master service plan shall be filed in the resident's record. A current copy shall be maintained in a location accessible at all times to direct care staff, but that protects the confidentiality of the contents of the service plan. Extracts from the plan may be filed in locations specifically identified for their retention, e.g., dietary plan in kitchen.

G. The facility shall ensure that the care and services specified in the individualized service plan are provided to each resident.

EXCEPTION: There may be a deviation from the plan when mutually agreed upon between the facility and the resident or the resident's legal representative at the time the care or services are scheduled or when there is an emergency that prevents the care or services from being provided. Deviation from the plan shall be documented in writing, including a description of the circumstances, the date it occurred, and the signatures of the parties involved, and the documentation shall be retained in the resident's record.

The facility may not start, change or discontinue medications, dietary supplements, diets, medical procedures or treatments without an order from a physician or other prescriber.

H. Outcomes shall be noted on the individualized plan or on a separate document as outcomes are achieved, and progress toward reaching expected outcomes shall be noted on the service plan or other document at least annually. Personnel making such notes shall sign and date them.

I. Individualized service plans shall be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. The review and update shall be performed by a staff person who has completed an ISP training program approved by the department, in conjunction with the resident, and as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals or other persons.

Historical Notes

Derived from Volume 23, Issue 06, eff. December 28, 2006; amended, Virginia Register Volume 25, Issue 08, eff. February 5, 2009.

Statutory Authority

§§ 63.2-217 and 63.2-1732 of the Code of Virginia.