Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 113 - Regulations Governing the Licensing and Functioning of Assisted Housing Programs (includes Assisted Living Programs, Residential Care Facilities, and Private Non-Medical Institutions) (formerly 10-149 Ch. 113)
Level III - Residential Care Facilities
Section 144-113-III-11 - Health Care and Access to Services

11.2.1 Assessments. Each resident shall be assessed within thirty (30) calendar days of admission. Reassessments must be completed annually or more frequently if there is a significant change in his/her condition. The assessments/reassessments are to determine each resident's abilities and need for services. Residents shall have an opportunity to receive individualized services that help them function in the facility and in the community and that help restore them to an optimal state of health, or for constructive activity, as needed. The facility will assure, to a practicable extent, that residents' needs will be accommodated regarding individual choices and preferences. This shall be evidenced in the assessment, in the development and implementation of individual service plans and in regular progress notes. The areas identified below are to be assessed. The resident and resident's guardian or other legal representative, as well as staff or other persons approved by the resident or resident's guardian who are knowledgeable about the resident, shall participate in or be consulted concerning the assessment. The listing of these areas is not meant to exclude assessment of any other obvious needs that residents may exhibit. The most current assessment shall be kept in the resident's record. Previous assessments shall be kept with the resident's active record.

11.2.2 Service plan. A service plan shall be developed and implemented within thirty (30) calendar days of admission for each resident based upon the findings of the assessment. The plan shall address those areas in which the resident needs encouragement, assistance or an intervention strategy. The resident, his/her legal representative (if applicable) and others chosen by the resident shall be actively involved in the development of the service plan, unless he/she is unable or unwilling to participate. There shall be documentation in the resident's record identifying who participated in the development of the service plan. The plan shall describe strategies and approaches to meet the resident's needs, names of who will arrange and/or deliver services, when and how often services will be provided and goals to improve or maintain the resident's level of functioning. Residents shall be encouraged to be as independent as possible in their functioning, including ADLs and normal household tasks if they choose, unless contraindicated by the resident's duly authorized licensed practitioner. The service plan shall be modified, as necessary, based upon identified changes. Residents shall never be required to perform activities specified in the residential service plan or any other activities and cannot be used to replace paid staff.

11.2.3 Progress notes. The facility shall maintain ongoing signed and dated progress notes at least monthly, on implementation of the service plan and for any significant changes in the resident's life including any increases or declines in the resident's physical and mental functioning that should be considered at the time of reassessment or adjustment in the service plan. Progress notes shall begin within twenty-four (24) hours of admission and shall include an initial summary of basic care needs, circumstances of resident's placement and resident's adjustment to the facility.