Section 295.4010  Service Plan

a)         Based on the physician's assessment and establishment evaluation (see Section 295.4000), a written service plan shall be developed and mutually agreed upon by the establishment and the resident. (Section 15 of the Act)  The establishment shall respect and accept the resident's choices regarding the service plan.

b)         The service plan shall be developed by:

1)         The resident, resident's representative or any individual requested by the resident;

2)         The manager or manager's designee; and

3)         A registered nurse, if the resident is receiving nursing services or medication administration, or is unable to direct self-care.

c)         The service plan shall be signed and dated by all individuals involved in its development.

d)         The service plan, which shall be reviewed annually, or more often as the resident's condition, preferences, or service needs change, shall serve as a basis for the service delivery contract between the provider and the resident (see Section 295.2030). (Section 15 of the Act)

e)         The service plan shall be reviewed and revised if necessary immediately after a significant change in the resident's physical, cognitive, or functional condition (see Section 295.4000).

f)         Based on the physician's assessment, the service plan may provide for the disconnection or removal of any kitchen appliance.  (Section 15 of the Act)

g)         Service plans shall address:

1)         The level of service the resident is receiving, including:

A)        assistance with activities of daily living;

B)        dietary needs, if the establishment provides therapeutic diets; and

C)        special accommodations for the resident;

2)         The amount, type, and frequency of health-related services needed by the resident;

3)         Staff responsible for the provisions of the service plan;

4)         Any risk being negotiated; and

5)         Whether the resident requires medication reminders, supervision of self-administered medication, or medication administration.

h)         The service plan shall include all support services provided or arranged for by the establishment.

i)          Nothing in this Part limits a resident's ability to direct his or her own care and negotiate the terms of his or her own care. Residents have the right to refuse certain services or approaches that would otherwise be recommended based on the physician's assessment if the resident has received clear information regarding the risks and benefits of such a choice and the choice does not put other residents or staff at risk.  Disclosure of the risks of refusing services or approaches must be documented in the service plan.