(a) Psychosocial and physical assessments.

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

   1. (A) The resident’s degree or level of family support;
   2. (B) The level of activities of daily living functioning;
   3. (C) Cognitive level;
   4. (D) Behavioral impairment; and
   5. (E) Identification of 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 disease or related dementia.

(b) IAT.

1. (1)

   1. (A) Within thirty (30) days after admission, the IAT shall prepare for each resident an 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.

2. (2) The IAT shall perform accurate assessments or reassessments annually, and upon a significant 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.

(c) ISP.

1. (1)

   1. (A) The ISP shall include a family and social history.
   2. (B) If the family and social history is unavailable, the ASCU personnel shall document attempts to obtain the information, including but not limited to:

(i) The names and telephone numbers of individuals contacted, or who the facility attempted to contact; and

1. (ii) The date and time of the contact or attempted contact.
2. (2) ISPs shall be developed and written by the IAT and signed by each member of the team.

3. (3)

   1. (A) ISPs shall have the input and participation of the resident or his or her responsible party and the resident’s family.

   2. (B)

      1. (i) If the resident's family or responsible party cannot be contacted or refuses to participate, the facility shall document all attempts to notify the resident’s family or legal representative.
      2. (ii) The documentation shall include, but not be limited to:

(b) (b) The date and time of the contact or attempted contact.

1. (4)

   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 is required, the ISP shall document the change of condition and the reason or reasons why no change in services is required.

2. (5) The ISP shall include:

   1. (A) Expected behavioral outcomes;
   2. (B) All 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 and 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.
3. (6) A copy of the ISP shall be made available to all staff that work with the resident and the resident or his or her responsible party.
4. (7) The ISP shall be implemented only with the documented, written consent of the resident or his or her responsible party.