1. (a) Psychosocial and physical assessments.

   1. (1) Each resident shall receive a psychosocial and physical assessment which:

      1. (A) Includes the resident’s:

2. (i) Degree or level of family support;

   1. (ii) Level of activities of daily living functioning;

      1. (iii) Cognitive level; and

         1. (iv) Behavioral impairment; and
      2. (B) Identifies the resident’s strengths and weaknesses.
   2. (2) Prior to admission to the ASCU, the applicant must be evaluated by, and have received from a physician, a diagnosis of Alzheimer’s or related dementia.

3. (b) Individual assessment team (IAT).

   1. (1)

      1. (A) Within thirty (30) days after admission, the IAT shall prepare for each resident an individual support plan (ISP).
      2. (B) The ISP shall address specific needs of, and services required by, the resident resulting from the resident’s Alzheimer’s disease or related dementia.

      3. (C) The plan shall include and identify professions, disciplines, and services that:

         1. (i) Identify and state the resident's medical needs, social needs, disabilities, and their causes;
         2. (ii) Identify the resident's specific strengths;
         3. (iii) Identify the resident's specific behavioral management needs;
         4. (iv) Identify the resident's need for services without regard to the actual availability of services;
         5. (v) Identify and quantify the resident's speech, language, and auditory functioning;
         6. (vi) Identify and quantify the resident's cognitive and social development; and
         7. (vii) Identify and specify the independent living skills and other services provided by the ASCU to meet the needs of the resident.

   2. (2) The IAT shall perform accurate assessments or reassessments annually, and upon a change to a resident’s physical, mental, emotional, functional, or behavioral condition or status in which the resident:

      1. (A) Is regressing in, or losing, skills already gained;
      2. (B) Is failing to progress toward or maintain identified objectives in the ISP; or

      3. (C) Is being considered for changes in the resident’s ISP.

         1. (c) Individual support plan (ISP).

   3. (1)

      1. (A) The ISP shall include a family and social history.

      2. (B) If the family and social history cannot be obtained, the ASCU personnel shall document attempts to obtain the information, including but not limited to, the:

         1. (i) Names and telephone numbers of individuals contacted, or whom the facility attempted to contact; and
         2. (ii) Date and time of the contact or attempted contact.

   4. (2)

      1. (A) The ISP shall be reviewed, evaluated for its effectiveness, and updated at least quarterly, and shall be updated when indicated by changing needs of the resident, or upon any reassessments by the IAT.

      2. (B) In the event that the reassessment by the IAT documents a change of condition for which no change in services to meet resident needs are required, the ISP shall document the:

         1. (i) Change of condition; and
         2. (ii) Reason or reasons why no change in services are required.

   5. (3) The ISP shall include:

      1. (A) Expected behavioral outcomes;
      2. (B) Barriers to expected outcomes;
      3. (C) Services, including frequency of delivery, designed to achieve expected behavioral outcomes;

      4. (D)

         1. (i) Methods of assessment and monitoring.
         2. (ii) Monitoring shall occur no less than quarterly to determine progress toward the outcome;
      5. (E) Documentation of results from services provided, achievement towards expected outcomes or regression, and reasons for the regression; and
      6. (F) The resident’s likes, dislikes, and if appropriate, his or her choices.

   6. (4) A copy of the ISP shall be made available to:

      1. (A) All staff that work with the resident; and
      2. (B) The resident or his or her responsible party.
   7. (5) The ISP shall be implemented only with the documented, written consent of the resident or his or her responsible party.

Codification Notes: “ASCU” means Alzheimer’s special care unit.