Resident assessment and Individual Service Plan (ISP) development is a cyclical process common to all assisted living communities, regardless of a community’s license category. It is recognized that not all assisted living categories have the same requirements related to resident assessment and ISP development, but the concept is the same: assessing the resident’s needs and developing care consistent with those assessed needs, the resident’s wishes, and your community’s program statement.
The cycle of assessment and ISP development is ongoing. The ISP must be reviewed and updated as required by license category and whenever there is a change in the resident’s needs or condition. The ISP is reviewed for effectiveness by reevaluating the resident’s outcomes, progress toward achieving ISP goals and/or changing needs. The ISP is then updated to reflect changes and implement new care strategies.
Know your responsibility as an Assisted Living Provider
The Bureau of Assisted Living does not require that you use an approved form for assessments or ISPs. However, the provider is responsible for developing and using tools or documents that ensure the completion of a comprehensive and thorough assessment and ISP that meets all regulatory requirements.
Although DHS specifies the topics that need to be included in an assessment, simply addressing all the topics on DHS’s list will not guarantee that your staff will acquire all the information necessary to provide your residents all the care and services they need. You may need to ask about topics not specified by DHS. A resident assessment should be regarded as a collaborative process of ongoing conversations directed by residents in partnership with caregivers and other supporters, to identify the resident’s strengths, capacities, preferences, and desired outcomes. This will ensure that all parties have the best information to attempt to satisfy the needs and goals of the resident.
To evaluate your assessment tool, ask:
- Does it clearly identify the information you are required to gather or assess?
- Is the information and questions organized in a clear, logical order?
- Does it meet the requirements of your program statement and your respective Administrative Code, including all the required areas of assessment?
- Does it identify treatments or services that your community is or is not capable of providing?
- Does it identify risk factors that trigger a requirement for further assessment before determining whether you can safely admit the resident?
The other tool, the ISP, gives direction to staff on how to provide care, assistance, and support. It includes specific information about care, either prescribed by a practitioner or agreed upon by the individual and/or their representatives and the community. It also identifies who will provide the care, assistance, support, and the frequency of care. Along with care directives, the ISP provides care staff with the “big picture” or holistic view of the resident. The content should include important descriptions of the person in addition to directives regarding the tasks to perform to provide care in a manner that meets the resident’s lifestyle preferences.
The Wisconsin Assisted Living Association’s ISPs and Assessments – Standards of Practice manual is designed to help ensure that your documents fit not only DHS’s standards but help you provide the best care to your residents. This guide offers several examples of ISPs and references included in this manual as well as many other tools.
- Understand the content required to be included in assessments.
- Learn how to conduct assessments and ISPs meetings.
- Know how to evaluate and revise ISPs.
- Offers sample ISPs and assessments you can use in your community.
Order WALA’s ISPs and Assessments – Standards of Practice at the WALA Store at www.ewala.org or call 608/288-0246. This Standard of Practice is available in hard copy or as a download at a reduced price.
WALA Member Pricing – Hard Copy: $50.00 with template CD Download: $30.00
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