A Program for caregivers working in Virginia’s

licensed assisted living facilities.

Individualized Service Plans: Meeting

Resident Needs

1 8/2018

2

What do I need

to know to

support this

individual with

their care

needs?

3

At the end of this program, you will be

able to… Read and interpret the Uniform Assessment Instrument (UAI).

Identify the Virginia licensing standards and regulations governing the

completion and revision of the UAI and ISP.

Understand/explain what is meant by the phrase “significant change”.

Discuss how ISPs can promote teamwork.

Identify resident needs from the UAI and other assessment resources.

Understand the difference between a diagnosis and a need.

Discuss ways to individualize an ISP.

Develop and use goal oriented ISPs for your residents.

4

5

Title 63.2 of the Code of Virginia

Standards for Licensed Assisted Living Facilities

Technical Assistance for Standards for Licensed

Assisted Living Facilities

Applicable Core Standards

Standards for Licensed Assisted Living Facilities

Definitions: 22 VAC 40-73-10

Uniform Assessment Instrument: 22 VAC 40-73-440

Individualized Service Plans: 22 VAC 40-73-450

To access these regulatory standards go to: www.dss.virginia.gov

6

UAI: The Foundation of an ISP

An assessment tool.

Provides core of the ISP.

Know how to read.

Know how to interpret into needs.

7

UAI: Purpose

To gather information to determine care needs.

To determine if a person’s needs can be met by the facility.

To determine eligibility for certain services.

To plan and monitor care between agencies.

To keep a record of changes in resident status.

To determine level of care.

8

UAI: Functional Assessment

Activities of Daily Living (ADLs).

Instrumental Activities of Daily Living (IADLs).

Psycho-social status.

9

Best Practices Notes

Psycho-Social Assessment:

Life history.

Sources of comfort, fright, and joy.

Privacy and environment preferences.

Family dynamics and support issues.

Grieving and loss.

Transfer trauma.

Go the extra mile to know your residents.

10

Know the person!

11

UAI: Describing Function

I = independent.

d = semi-dependent.

D = dependent (human help only).

D = dependent (human & mechanical help).

D or TD = Totally dependent.

http://www.dss.virginia.gov/files/division/dfs/as/as_intro_p

age/manuals/uai/uai_manual_feb__2017.pdf

12

More about Functional Status

Important points:

Both impairment level and need for assistance.

Ability, not preference.

Past 2 weeks’ performance.

All components of the task.

13

Activity: Functional Assessment

1. Mr. Roberts uses a cane only on days when he feels tired or out of

breath.

2. Mr. Heath sits down when he is out of breath.

3. Mrs. Harper needs a mechanical lift or two-person transfer to get

from her bed to her wheelchair. She can give no help.

4. Mr. Conrad needs someone to put the sock and shoe on his weak

side. He can take care of the other foot by himself.

14

UAI: Requirements

Standards for Licensed Assisted Living Facilities

Private Pay: 22 VAC 40-73-440 B 1

Public pay: 22 VAC 40-73-440 E

15

UAI: What, Who, When

Public Pay Private Pay What

Part A, Behavior Pattern, Medication Administration (all)

Parts A & B (Dependant in 2+ ADLs or Behavior)

Who Qualified Assessor, Case

Managers, Independent Physicians

When Prior to admission (within 90

days) Every 12 months After a significant change

What

An abbreviated UAI – 2 pages

Who

ALF employee who has successfully completed UAI training, Independent Physicians, Case Managers, Qualified Assessor

When

Prior to admission (within 90 days)

Every 12 months

After a significant change

16

UAIs: Updating UAIs

Required at least every 12 months

AND

Required when a resident’s change in condition is expected

to last more than 30 days

OR

Whenever a resident’s change in status appears to warrant a

change in level of care.

17

Check-up Point

Which of the following might be a significant change?

1. A woman needing incontinence pads for the first time

during a urinary tract infection.

2. A man needing a walker following a stroke.

3. A man with memory loss who starts becoming agitated

during bathing.

4. A woman who suddenly requests to eat in her room.

18

FAQs: Frequently Asked Questions

What happens to the UAI when a resident is transferred?

Can updates to a UAI be made on the existing form?

What happens when a new resident acts differently than

described on their initial assessment?

Can an administrator designate more than one staff member

to approve and sign completed UAIs?

Can you approve and sign a UAI you yourself completed?

19

Check-up Point

1. When does a UAI need to be completed?

2. What 3 types of functioning abilities can be found on a

UAI?

3. According to regulations, when must a UAI be updated?

4. Describe what ‘significant change’ means. Give one

possible example.

20

Activity: Your Dream House

21

Building Your House

22

Your Construction Team

23

ISP: A Blueprint for Care

24

ISP: Model Forms

This table is for discussion only. It is not a model form.

Needs/

Dates

Services Who When/Where Expected

Outcomes/Goals/

Time Frames

Date

Outcome

Achieved

25

Who can complete ISPs?

The licensee/administrator or designee who has completed the DSS approved ISP training program. State approved private pay UAI training must be completed as a prerequisite to ISP training.

+ input from: Resident and family.

Case worker and/or case manager.

Other healthcare workers and other persons, as appropriate.

26

When are ISPs completed?

On or within 7 days prior to the day of admission a

preliminary plan of care shall be developed to address the

basic needs of the resident.

Comprehensive plan – within 30 days of admission.

In writing.

27

When are ISPs revised?

Reviewed and updated at least every 12 months.

Reevaluated as resident’s condition changes-significant change.

28

Where are ISPs kept?

Accessibility is necessary. Master plan-resident’s

record.

Copy to resident.

Copies in locations accessible to staff responsible for services.

Privacy is a priority.

Plan for routine use.

Not under lock and key!

A blueprint provides no guidance

if it is filed away out of sight!

29

Application: Your FacilityConsider these questions in terms of your own workplace:

• Where are all the copies of ISPs located in your facility?

• To your knowledge, how often do members of the nursing staff refer to ISPs?

• Do you think it would be helpful to your colleagues to make any changes regarding the everyday use of ISPs?

• What might some of those changes be?

• How is the information in a resident’s ISP shared with new employees?

• In general, what value does the staff in your facility place on ISPs?

30

ISPs: Important Points

Signing the ISP.

IADLs.

Preprinted ISPs.

Find the Technical Assistance at:

http://www.dss.virginia.gov.

Assistance.

Applicable Regulations, Technical Assistance & Code References.

31

Q: Who signs an ISP?

Licensee/administrator.

Designee.

Resident or legal representative.

32

Q: Must IADLs be included?

YES!

Reflect assessed needs.

Services routinely provided.

Availability of documentation.

33

Q: Are preprinted or electronic ISPs

acceptable?

Specific choices.

Types of assistance.

Extent of assistance.

Could a float, PRN, new staff or family member

understand?

34

ISPs: More Important Points

19 or fewer residents.

Independent status.

Respite care.

Reviewing and monitoring.

Case manager.

Do Not Resuscitate Order.

Hospice/Private Duty/Other

Services.

35

ISP: The Role of the Reviewer

Review.

Monitor.

Implement.

Modify.

Inform.

36

Reviewing ISPs

Review:To “see again”.

37

Monitoring ISPs

Monitor:To watch, to keep track of.

38

Implementing ISPs

Implement:To carry out; to accomplish.

39

Modifying ISPs

Modify:To make changes to serve a new end.

40

Informing about ISPs

Inform: To communicate knowledge of special interest or importance; to give information.

41

Check-Up Point

For your workplace:

1. When must the ISP be completed?

2. When must it be changed or updated?

3. List at least 3 of the duties of the staff member who

reviews ISPs.

42

ISPs: Useful Concepts

1. Habilitation vs. rehabilitation.

2. Maintaining status.

43

#1: Habilitation vs. Rehabilitation

Habilitation Rehabilitation

Adaptation & coping.

Secondary disability.

Following through, not

initiating.

Restorative.

Therapist-initiated.

Documented.

44

#2: To Maintain, or Not?

An assisted living goal is never to

“Maintain status.”

0

1

2

3

4

45

Know Your Goal!

When writing ISPs, consider what staff actually needs to do. What must happen for the job to be done well?

Habilitation or rehabilitation? Maintain or maximize function?

What do staff need to know about the individual to provide care?

46

What makes an ISP work?

Based on assessed needs.

Reasonable outcomes.

Fluid.

Accessible.

Teamwork.

Individualized.

47

ISP: A Plan for Teamwork

Different roles, one plan.

Family involvement.

Task breakdown.

Responsibility.

48

Activity: A Hospital Experience

49

ISP Requirements

Maximize the resident’s level of functional ability.

Home-like environment.

Services reflecting needs.

Freedom of choice.

Personal dignity.

Individuality.

50

No Cookie Cutter ISPs!

51

Mrs. Simms: Example Resident

78-year-old, widowed 12 yrs.

Married 46 yrs to a small town

businessman, later mayor.

Catholic faith, regular attendee.

No children.

Homemaker and volunteer during married

life and widowhood.

Enjoys knitting.

52

Mrs. Simms: Example Resident

• 78-year-old, widowed 12 yrs.

• Married 46 yrs to a small town

businessman, later mayor.

• Catholic faith, regular attendee.

• No children.

• Homemaker and volunteer during married

life and widowhood.

• Enjoys knitting, NASCAR races.

• Has held a season’s ticket to the Redskins’

game for 10 yrs.

53

Sources of Information

• Interviews.

• UAI & other assessments.

• History & Physical.

• Medical reports.

• Therapists & rehab.

• Mental health.

• Home health.

• Observations.

• Family, friends, clergy, etc.

54

Needs & Dates

Need vs. diagnosis.

ADLs and IADLs.

Date identified.

Why did this person come to assisted living?

55

Hello, Mrs. Simms

History and Physical –

CVA in 2003.

Right-sided weakness.

Attended rehab.

56

Mrs. Simms’ Needs

Functional Status: UAI, Section 2

Dressing.

Ambulation.

Home maintenance.

Meal preparation.

57

Mrs. Simms’ Needs

Functional Status: UAI, Section 2

Dressing – MH & HH.

Ambulation – MH Only.

Home Maintenance – I (Independent).

Meal preparation – Needs help.

58

Services

What the staff will do…

What the facility will do…

Specifically.

59

It’s all about verbs.

• Assist

• Organize

• Facilitate

• Supervise

• Provide

• Carry out

• Accompany

• Arrange for

• Set up

• Reorient/validate

• Listen

• Praise/encourage

• Reinforce

• Monitor

….by….

The direct care staff will …

60

Services: One Final Word

Individuality.

Independence.

Freedom of choice.

61

Mrs. Simms and her ISP

Description of Needs and Date Identified Services to be Provided

Dressing assistance with bras, stockings,

zippers, etc.

06/25/18

62

Mrs. Simms and her ISP

Description of Needs and Date

Identified

Services to be Provided

Dressing assistance with bras, stockings,

zippers, etc.

06/25/18

• Verbal cues for maximum use of assistive

devices

•Assist with opening/closing of fasteners

• Stand-by assist. For undergarments – by

resident request only.

• Stand-by assist. For balance.

63

Persons who will provide services Direct care staff.

Nurse aid/CNA.

Licensed nursing staff.

Activity department.

Dietary/dining department.

Maintenance/housekeeping.

Private Duty Nurses/Companions.

Administration.

Hospice personnel.

Family.

Physical/occupational therapy.

Transportation.

64

When & Where

# Times per day.

# Days per week.

Throughout the day.

AM & PM.

Upon rising and before

retiring.

In resident’s apartment.

Throughout the facility.

Common areas.

Per doctor’s orders.

During scheduled

mealtimes.

Dining room and

resident’s apartment.

65

Expected Outcomes/Goals

“The resident will…”

Reasonable.

Appropriate.

Measureable or observable.

Maximum function.

Never… ‘Maintain status.’

66

Setting Goals

What is the need?

Why does the need exist?

What improvements can be expected?

What will facilitate improvement?

How long will progress be measured?

How long will it take?

What to do when the goal is met?

67

Same Need – Different Goals &

Services

68

Mrs. Simms returns

Needs

& Date

Services Who When/Where Expected

Outcomes/

Goals

Date

Outcome

Achieved

Dressing

06/25/18

•Verbal cues…

•Assist…fasteners

• Stand-by… request

• Stand-by… balance

69

Mrs. Simms returns

Needs

& Date

Services Who When/Where Expected

Outcomes/ Goals

Date

Outcome

Achieved

Dressing

06/25/

18

•Verbal cues…

•Assist…fasteners

• Stand-by…

request

• Stand-by…

balance

Direct

Care

Staff;

Nursing

Staff

Daily AM care

& PM care,

and as needed

In resident’s

apartment

Resident will be

dressed in clean,

neat clothes of

her choice on a

daily basis.

She will

participate in

dressing herself

to the maximum

extent of her

ability.

70

Time Frames

Designate on ISP.

Outcome measurement tool.

71

Hints & Tips

What is the need?

Why does the need exist?

What can reasonably be expected?

What will facilitate maximum functioning?

How will goal achievement be measured?

How long will it take?

Who is going to do it?

What does staff need to know to provide care for the

resident?

72

The 5-Step Method

1. Gather information.

2. Identify needs.

3. Develop the plan.

4. Implement the plan.

5. Evaluate.

(Then repeat from the top.)

73

1. Gather Information

Different sources.

UAI.

Multidisciplinary.

Reports and interviews.

74

2. Identify Needs

From assessments.

Include all identified needs.

No diagnoses.

“….has a need for assistance with….”

75

3. Develop the Plan

Appropriate form.

Clear, legible writing in ink.

One need per row of blocks.

Services to meet needs.

Who, when, and where.

Expected outcome of services.

Time frame.

How to measure.

76

4. Implement the Plan

Inform staff.

Copies where needed.

Teamwork.

Designated reviewer.

Review and revise per DSS standards.

77

5. Evaluate

Different levels, different focus:

As a document.

As a blueprint for care.

As an overall program review.

78

Common ISP ProblemsDon’t fall into these traps!

Substituting diagnosis for a

need.

Listing multiple needs in a

block.

Using generalities.

Using technical language.

Using too many abbreviations.

Using ‘maintain status’ as a

goal.

Illegible and messy.

Assuming reader

comprehension.

ISP developer not properly

trained.

ISP not used as daily care

guide.

Working copies not available.

Failure to cover all UAI needs.

79

Partnering with your Inspector

Different interpretations.

Culture of trust.

A member of the team.

Asking questions.

Moving forward.

Keep the big picture.

Bottom line = resident well-being.

80

Phone: (804) 828-1565

Website: https://chp.vcu.edu/departments/gerontology/

Email: agingstudies@vcu.edu

Be sure to “like” us on Facebook

https://www.facebook.com/vcugerontology

Thank You!

81