Section 481.69.26. Service plans.

         69.26(1) A service plan shall be developed for each tenant based on the evaluations conducted in accordance with subrules 69.22(1) and 69.22(2) and shall be designed to meet the specific service needs of the individual tenant. The service plan shall subsequently be updated at least annually and whenever changes are needed.

         69.26(2) Prior to the tenant’s signing the occupancy agreement and taking occupancy of a dwelling unit, a preliminary service plan shall be developed by a health care professional or human service professional in consultation with the tenant and, at the tenant’s request, with other individuals identified by the tenant, and, if applicable, with the tenant’s legal representative. All persons who develop the plan and the tenant or the tenant’s legal representative shall sign the plan.

         69.26(3) When a tenant needs personal care or health-related care, the service plan shall be updated within 30 days of the tenant’s occupancy and as needed with significant change, but not less than annually.

            a.               If a significant change triggers the review and update of the service plan, the updated service plan shall be signed and dated by all parties.

            b.               If a significant change does not exist, the program may, after nurse review, add minor discretionary changes to the service plan without a comprehensive evaluation and without obtaining signatures on the service plan.

            c.               If a significant change relates to a recurring or chronic condition, a previous evaluation and service plan of the recurring condition may be utilized without new signatures being obtained. For example, with chronic exacerbation of a urinary tract infection, nurse review is adequate to institute the previously written evaluation and service plan.

            d.               The service plan updated within 30 days of the tenant’s occupancy shall be signed and dated by all parties.

         69.26(4) The service plan shall be individualized and shall indicate, at a minimum:

            a.               The tenant’s identified needs and preferences for assistance;

            b.               Any services and care to be provided pursuant to the occupancy agreement;

            c.               The service provider(s), if other than the program, including but not limited to providers of hospice care, home health care, occupational therapy, and physical therapy;

            d.               For tenants who are unable to plan their own activities, including tenants with dementia, a list of person-centered planned and spontaneous activities based on the tenant’s abilities and personal interests; and

            e.               Preferences, if any, of the tenant or the tenant’s legal representative for nursing facility care, if the need for nursing facility care presents itself during the assisted living program occupancy.

[ARC 8176B, IAB 9/23/09, effective 1/1/10; ARC 2463C, IAB 3/16/16, effective 4/20/16]