Current through Register Vol. 47, No. 6, September 18, 2024
(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.
(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.
(3) When a tenant needs
personal care or health-related care, the service plan shall be updated within
3 0 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.
e. The service plan shall be reviewed,
updated if necessary, and signed and dated by all parties at least
annually.
(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.
