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Assisted Living Service Plan

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Assisted Living Service Plan Powered By Docstoc
					                                                                           Service Plan Evaluation Form
                            *Report any changes in resident condition to the Assisted Living Manager or Supervisor on duty*

Resident’s Name:_____________________________________________
Resident Allergies:____________________________________________                                                                         Resident is DNR:                  ○ Yes           ○ No



1.      Resident Medical Conditions to be aware of:_________________________________________________________________
2.      Resident Memory or Behavior Problems:____________________________________________________________________
3.      Resident is at risk for:___________________________________________________________________________________
4.      Resident Medications: ○ Staff Administers, ○ Resident Administers




        Key: I = Independent, CR = Cue & Remind, 1P = One Person Assist, 2P = Two Person Assist, EVE = Evening, NT = Night
                                                                                                                                                                    D     E    N
     Date                ADL Needs                       I     C    1    2               Services to be Provided                           When & How               A     V    T            By Whom
                                                               R    P    P                                                                    Often                 Y     E
                 Eating    Assistance
                     □     Special diet
                     □     Cut up food
                     □     Mechanical soft
                     □     Pureed
                     □     Escort to meals




        Source: This form was initially developed by the Legal Aid Bureau’s Nursing Home and Assisted Living Project in 2000. The work was funded by a Marie Walsh Sharpe partnership in law and aging
        grant. The policies and forms were reviewed and updated in August/September 2007 by the Legal Aid Bureau’s Senior Legal Helpline and the Maryland Legal Assistance Network under a grant from
        the Maryland Department on Aging.

        Date last reviewed (no legal content): 8/27/07 (MLAN AC/AB)
                                                                                                                                                               D     E    N
                                                    I     C    1    2               Services to be Provided                           When & How               A     V    T            By Whom
Date
                                                          R    P    P                                                                    Often                 Y     E

            Mobility Assistance
               □ Cane
               □ Escort to activities
               □ Walker
               □ Stairs
               □ WIC
               □ Bed
            Transfer Assistance




            Continence Assistance
               □ Incontinence bladder
               □ Incontinence bowel
               □ Toileting Schedule
            Bathing Assistance
            Showering
               □ Yes
               □ No
            Tub Bath
               □ Yes
               □ No
            Oral Care & Groom
            Dentures
               □ Upper
               □ Lower
               □ Partial




   Source: This form was initially developed by the Legal Aid Bureau’s Nursing Home and Assisted Living Project in 2000. The work was funded by a Marie Walsh Sharpe partnership in law and aging
   grant. The policies and forms were reviewed and updated in August/September 2007 by the Legal Aid Bureau’s Senior Legal Helpline and the Maryland Legal Assistance Network under a grant from
   the Maryland Department on Aging.

   Date last reviewed (no legal content): 8/27/07 (MLAN AC/AB)
                                                                                                                                                               D     E    N
                    ADL Needs                       I     C    1    2               Services to be Provided                           When & How               A     V    T            By Whom
Date                                                      R    P    P                                                                    Often                 Y     E



            Dressing Assistance




                                                                                                                                                               D     E    N
Date                IADL Needs                      I     C    1    2               Services to be Provided                           When & How               A     V    T           By Whom
                                                          R    P    P                                                                    Often                 Y     E
            Meal Preparation


            Housekeeping



            Shopping


            Managing Finances


            Transportation



   Source: This form was initially developed by the Legal Aid Bureau’s Nursing Home and Assisted Living Project in 2000. The work was funded by a Marie Walsh Sharpe partnership in law and aging
   grant. The policies and forms were reviewed and updated in August/September 2007 by the Legal Aid Bureau’s Senior Legal Helpline and the Maryland Legal Assistance Network under a grant from
   the Maryland Department on Aging.

   Date last reviewed (no legal content): 8/27/07 (MLAN AC/AB)
                                                                                                                                                               D     E    N
Date                IADL Needs                      I     C    1    2               Services to be Provided                           When & How               A     V    T           By Whom
                                                          R    P    P                                                                    Often                 Y     E
            Telephone Use




                                                                                                                                                               D     E    N
Date          Medical or psychiatric                        Monitoring or assessment to be provided                                  When & How                A     V    T           By Whom
              illnesses or conditions                                                                                                   Often                  Y     E




   Source: This form was initially developed by the Legal Aid Bureau’s Nursing Home and Assisted Living Project in 2000. The work was funded by a Marie Walsh Sharpe partnership in law and aging
   grant. The policies and forms were reviewed and updated in August/September 2007 by the Legal Aid Bureau’s Senior Legal Helpline and the Maryland Legal Assistance Network under a grant from
   the Maryland Department on Aging.

   Date last reviewed (no legal content): 8/27/07 (MLAN AC/AB)
                                                                                                                                                               D     E    N
Date        Treatment for physical or                             Care or service to be provided                                     When & How                A     V    T          By Whom
               Medical conditions                                                                                                       Often                  Y     E




Date         Medication Management




            Risk Factor Management                                                                                                                             D     E    N
Date         (falling, nutrition, skin                           Care or service to be provided                                      When & How                A     V    T          By Whom
                       health)                                                                                                          Often                  Y     E




   Source: This form was initially developed by the Legal Aid Bureau’s Nursing Home and Assisted Living Project in 2000. The work was funded by a Marie Walsh Sharpe partnership in law and aging
   grant. The policies and forms were reviewed and updated in August/September 2007 by the Legal Aid Bureau’s Senior Legal Helpline and the Maryland Legal Assistance Network under a grant from
   the Maryland Department on Aging.

   Date last reviewed (no legal content): 8/27/07 (MLAN AC/AB)
            Risk Factor Management                                                                                                                             D     E    N
Date         (falling, nutrition, skin                             Care or service to be provided                                    When & How                A     V    T          By Whom
                       health)                                                                                                          Often                  Y     E




             Management of Problem                                                                                                                             D     E    N
Date              Behavior                                       Care or service to be provided                                      When & How                A     V    T          By Whom
                                                                                                                                        Often                  Y     E




                                                                                                                                                               D     E    N
Date                Other Needs                                            Service Provided                                          When & How                A     V    T           By Whom
                                                                                                                                        Often                  Y     E




   Source: This form was initially developed by the Legal Aid Bureau’s Nursing Home and Assisted Living Project in 2000. The work was funded by a Marie Walsh Sharpe partnership in law and aging
   grant. The policies and forms were reviewed and updated in August/September 2007 by the Legal Aid Bureau’s Senior Legal Helpline and the Maryland Legal Assistance Network under a grant from
   the Maryland Department on Aging.

   Date last reviewed (no legal content): 8/27/07 (MLAN AC/AB)
                                                                                                                                                                  D     E    N
   Date                Other Needs                                            Service Provided                                          When & How                A     V    T           By Whom
                                                                                                                                           Often                  Y     E




Assistive Devices (assign code: I, CR, 1P, 2P)                                                                   Other Special Instructions or Family Requests

○ Eye Glasses [____]                         ○ Hearing Aid [____]    ○ Upper Denture [____]   ___________________________________________
○ Brace or device [____]              ○   Lower Denture [____] ○ Prosthesis [____]      _________________________________________________
○_____________________________                             ○_____________________________                                  _________________________________________________
                                                                                                                           _________________________________________________

___________________________________                                   __________________                         ____________________________                                    ___________________
Assisted Living Manager                                               Date Completed                             Family / Responsible Party                                      Date

                      *NOTE: All revisions to this plan must be dated and approved by Assisted Living Manager.
Plan Review / Modifications:    _______________     _______________    ________________ ________________ __________________
                                Date                Date               Date             Date              Date

Biannual Review Completed                                                                             Biannual Review Completed
      Signature / Date                                                                                      Signature / Date
      Source: This form was initially developed by the Legal Aid Bureau’s Nursing Home and Assisted Living Project in 2000. The work was funded by a Marie Walsh Sharpe partnership in law and aging
      grant. The policies and forms were reviewed and updated in August/September 2007 by the Legal Aid Bureau’s Senior Legal Helpline and the Maryland Legal Assistance Network under a grant from
      the Maryland Department on Aging.

      Date last reviewed (no legal content): 8/27/07 (MLAN AC/AB)

				
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