Assisted Living Service Plan Samples Details

Have you ever struggled to create a service plan for a client? If so, you're not alone. Luckily, there's a helpful form that can make the process much easier. The Individualized Service Plan Form is designed to help service providers develop tailored service plans that meet the unique needs of their clients. The form can be used to document services provided, objectives achieved, and progress made. It's also a great tool for tracking client involvement and participation in goal setting. Simply fill out the form each time you work with a client, and you'll have an up-to-date record of their individualized service plan.

The listing includes information regarding the individualized service plan form. You can study it just before writing the gaps.

QuestionAnswer
Form NameIndividualized Service Plan Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesindividualized service plan form, individual service plan forms, service plan forms for assisted living, blank isp forms

Form Preview Example

 

Assisted Living Individualized Service Plan (ISP)

Resident Name:

 

 

Female Male

Date:

 

For: Initial Six months Other ___________

Note: Services to be provided and by whom: Any additional information or change of service on this ISP must be indicated in bold type, capital letters, or by using a different color ink and dated. Indicate the reason for any change in service in the last column, and the date of the change.

Key: N/A = Not Applicable, RA = Resident Aide, N = Nurse, P = Physician, L = Lab Tech, T = Therapist, O = Other

Part 1 – Care Needs

Activity – Check all

 

Services to be provided:

 

Frequency

By

Changes/Comments

applicable

 

 

 

 

Whom

 

 

 

 

 

 

 

 

Medical - Nursing

 

 

 

 

 

 

 

 

 

 

 

 

 

Lab Test

 

 

 

 

 

 

 

 

 

 

 

 

 

Pacemaker

 

 

 

 

 

 

 

 

 

 

 

 

 

Dialysis

 

 

 

 

 

 

 

 

 

 

 

 

 

Skilled Nursing,

 

Injection Insulin

 

 

 

 

Treatments &/or

 

 

 

 

 

Education

 

Other Type __________________

 

 

 

 

 

 

Dressing

 

 

 

 

 

 

Other ________________________

 

 

 

 

 

 

 

 

 

 

 

Specialists (eg

 

Specify________________________________

 

 

 

 

podiatrist,

 

 

 

 

 

chiropractor)

________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Equipment

 

Independent

 

 

 

 

 

 

Type _______________

 

 

 

 

 

 

1+ Assist (requires more than

 

 

 

 

 

intermittent assistance with equipment

 

 

 

 

 

EALR required)

 

 

 

 

 

 

 

 

 

 

 

Pain Management

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

health prevention

 

 

 

 

 

 

aide-level health related activities

 

 

 

 

 

 

other specify____________________

 

 

 

 

__________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rehabilitation

PT

OT

Speech Therapy

Other: ____________________

Nutritional

Diet Meal Assist

Regular NAS NCS

Chopped as needed Soft

Dietary Supplement

Specify: _____________________

Meals

Snacks

Chewing Difficulty

Swallowing Difficulty

Other: _______________

Resident Name: ________________________________________ Date: ____________

ISP Page 2 of 5

 

 

 

 

 

 

 

Activity – Check all

Services to be provided:

 

Frequency

By

 

Changes/Comments

applicable

 

 

 

 

 

Whom

 

 

Fluid Restrictions/

None

 

 

 

 

 

 

 

Encouragement

Dietary Supplements _______________

 

 

 

 

 

Other Specify: __________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Functional

 

 

 

 

 

 

 

 

Personal Hygiene

Independent

 

 

 

 

 

 

 

Shower

Bath

Equipment

 

 

 

 

 

Hearing Aide:

R

L

 

 

 

 

 

Eyeglasses Reading Always

 

 

 

 

 

Hair: Shampoo Grooming Shave

 

 

 

 

 

Teeth Care Denture Care

 

 

 

 

 

Nail Care

Foot Care

 

 

 

 

 

Continence

Independent

 

 

 

 

 

 

 

Assist with bathroom

 

 

 

 

 

 

Assist with protective garment change

 

 

 

 

 

Ostomy Care

 

 

 

 

 

 

 

Chronic unmanaged incontinence

 

 

 

 

 

(chronically unwilling or unable to

 

 

 

 

 

participate, with help from staff, so that

 

 

 

 

 

cleanliness and sanitation can be

 

 

 

 

 

maintained - EALR required)

 

 

 

 

 

 

 

 

 

 

 

 

 

Skin Care

None

 

 

 

 

 

 

 

 

Location & Type: _________________

 

 

 

 

 

 

 

 

 

 

 

 

Dressing

Independent

 

 

 

 

 

 

 

Coordinate Upper Lower

 

 

 

 

 

Other _________________________

 

 

 

 

 

 

 

 

 

 

 

 

Medications

Self Assist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Transfer

Independent

 

 

 

 

 

 

 

1+ Assist (chronically chairfast and/or

 

 

 

 

 

chronically needs one person assist to

 

 

 

 

 

transfer EALR required)

 

 

 

 

 

 

 

 

 

 

 

 

Mobility

Independent

Walker Cane

 

 

 

 

 

Wheelchair

Crutches

 

 

 

 

 

 

Escort: _______________________

 

 

 

 

 

1+ Assist (chronically needs one person

 

 

 

 

 

to assist to walk or to climb/descend stairs-

 

 

 

 

 

EALR required)

 

 

 

 

 

 

Falls Risk Reduction

No Known History

 

 

 

 

 

 

Other: __________________________

 

 

 

 

 

 

 

 

 

 

 

Respiratory Therapy

None Self-managed

 

 

 

 

 

& Oxygen

Type: _________________________

 

 

 

 

 

 

 

 

 

 

 

Equipment

None Self-managed

 

 

 

 

 

 

Prosthesis

Braces

 

 

 

 

 

 

Other __________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

Resident Name: ________________________________________

Date: ____________

ISP Page 3 of 5

 

 

 

 

 

 

 

Activity – Check all

Services to be provided:

 

Frequency

By

 

Changes/Comments

applicable

 

 

 

Whom

 

 

Cognitive

 

 

 

 

 

 

Orientation

N/A Remind Cue Supervise

 

 

 

 

 

 

Accompany

 

 

 

 

 

Specialized Services

N/A

 

 

 

 

 

 

Dementia Care, Secured Unit (requires

 

 

 

 

 

 

SNALR)

 

 

 

 

 

 

Environmental modifications

 

 

 

 

 

 

Supervision/Monitoring

 

 

 

 

 

 

 

 

 

 

 

 

Sensory

None

 

 

 

 

 

 

Hearing Vision Speech

 

 

 

 

 

 

Other: ________________________

 

 

 

 

 

 

 

 

 

 

 

 

Mental Health

Diagnosis: _____________________

 

 

 

 

 

 

Treatment Required ___Yes ___No

 

 

 

 

 

 

Substance Abuse

 

 

 

 

 

 

Coordination with SA

 

 

 

 

 

 

provider__________________________

 

 

 

 

 

 

 

 

 

 

 

 

Social

 

 

 

 

 

 

Education &

Desire for continued or future education:

 

 

 

 

 

Employment

Yes No

 

 

 

 

 

 

If yes, specify: ___________________

 

 

 

 

 

 

Desire to work or volunteer

 

 

 

 

 

 

Yes No

 

 

 

 

 

 

If yes, specify: __________________

 

 

 

 

 

 

 

 

 

 

 

 

Intellectual

Desire for new or continued intellectual

 

 

 

 

 

 

activity

 

 

 

 

 

 

Yes No

 

 

 

 

 

 

If yes, specify: ___________________

 

 

 

 

 

 

 

 

 

 

 

 

Recreational

Desire for new or continued recreational

 

 

 

 

 

 

activity

 

 

 

 

 

 

No Yes, Specify: _______________

 

 

 

 

 

 

Need assistance of ALR staff

 

 

 

 

 

 

Specify: ______________________

 

 

 

 

 

 

 

 

 

 

 

 

Spiritual

Desire for new or continued spiritual activity

 

 

 

 

 

 

No Yes, Specify: ________________

 

 

 

 

 

 

Need assistance of ALR staff

 

 

 

 

 

 

Specify: _________________________

 

 

 

 

 

 

 

 

 

 

 

 

Cultural

Desire for new or continued cultural activity

 

 

 

 

 

 

No Yes, Specify: ________________

 

 

 

 

 

 

Need assistance of ALR staff

 

 

 

 

 

 

Specify: _________________________

 

 

 

 

 

 

 

 

 

 

 

 

Financial

Assistance with access to financial benfits

 

 

 

 

 

 

(i.e. Medicare, Medicaid, Social Security,

 

 

 

 

 

 

Veteran’s Admin., Pensions, etc.)

 

 

 

 

 

 

Managed Independently

 

 

 

 

 

 

Assistance of family, resident rep. or

 

 

 

 

 

 

legal rep. Specify: __________________

 

 

 

 

 

 

Need assistance of ALR staff

 

 

 

 

 

 

Specify: _________________________

 

 

 

 

 

Resident Name: ________________________________________

Date: ____________

ISP Page 4 of 5

Other

Comments:

Print Name, Title and Organization of Individuals Participating

Resident

Resident’s Representative

Resident’s Legal Representative (if applicable)

ALR Provider’s Representative

Was the Resident’s Primary Physician Consulted?

 

 

Yes

Indicate physician’s name and date:

______________________________

_________________

No

 

 

 

 

__________________________________________

________________________________________

__________________

Home Care Services Agency Rep. Signature

ALR Provider’s Representative Signature

Date

(if applicable)

Documentation of ISP Review: For 6-month ISP reviews please consider and review any changes in the following

areas: Communication/Dental/Vision/Hearing; Customary Routine, Continence Status/Management, Physical Function, Cognitive Impairment Screen, and Admission Decision.

I am confirming the ISP services as listed above, including any changes that have been made since the last review.

I have reviewed the ISP services as listed above and recommend the following change(s) in service: __________

______________________________________________________________________________________________

_______________________________

______________________

____________

______________________

Name

Title

Date

Signature

 

 

 

 

 

 

 

 

 

 

 

 

Documentation of ISP Review: For 6-month ISP reviews please consider and review any changes in the following

areas: Communication/Dental/Vision/Hearing; Customary Routine, Continence Status/Management, Physical Function, Cognitive Impairment Screen, and Admission Decision.

I am confirming the ISP services as listed above, including any changes that have been made since the last review.

I have reviewed the ISP services as listed above and recommend the following change(s) in service: __________

______________________________________________________________________________________________

_______________________________

______________________

____________

______________________

Name

Title

Date

Signature

Attach Documentation of additional ISP Reviews as Necessary

Resident Name: ________________________________________

Date: ____________

ISP Page 5 of 5

Assisted Living Individualized Service Plan

Addendum for Enriched Housing Program/Assisted Living Residences

(If applicable)

Note: Services to be provided and by whom: Any additional information or change of service on this ISP must be indicated in bold type, capital letters, or by using a different color ink and dated. Indicate the reason for any change in

service in the last column, and the date of the change.

Key: N/A = Not Applicable, RA = Resident Aide, N = Nurse, P = Physician, L = Lab Tech, T = Therapist, O = Other

The following information pertains to additional tasks not included on the ISP relating to the enriched housing program functional assessment

Activity

Services to be provided:

Frequency

By

Whom

Changes/Comments

Instrumental

 

 

 

 

Activities of Daily

 

 

 

 

Living

 

 

 

 

Transportation

independent, drives own car or accesses

 

 

 

 

transportation on own & chooses to do so

 

 

 

 

wants or needs someone to drive them,

 

 

 

 

but does not require an escort

 

 

 

 

must be accompanied by an escort

 

 

 

 

requires special transportation

 

 

 

 

specify ___________________

 

 

 

 

 

 

 

 

Laundry

is able & chooses to do own laundry

 

 

 

 

is able & chooses to do light laundry, but

 

 

 

 

wants/needs assistance with heavy laundry

 

 

 

 

needs or chooses ALR to do all laundry

 

 

 

 

 

 

 

 

Housekeeping

is able & chooses to do all housekeeping

 

 

 

 

tasks in room/apartment

 

 

 

 

is able & chooses to do light

 

 

 

 

housekeeping, but wants/needs assistance

 

 

 

 

with heavier cleaning tasks

 

 

 

 

Specify _________________________

 

 

 

 

needs or chooses ALR to do all

 

 

 

 

housekeeping

 

 

 

Shopping

is able & chooses to shop on their own &

 

 

 

 

carry or transport packages on their own

 

 

 

 

is able & chooses to do light shopping on

 

 

 

 

their own, but wants/needs assistance with

 

 

 

 

major shopping

 

 

 

 

Specify _________________________

 

 

 

 

needs or chooses ALR staff or other

 

 

 

 

person (i.e. family member) to do all of their

 

 

 

 

shopping

 

 

 

Ability to use

Independent-has phone & dials numbers

 

 

 

telephone

and answers calls without assistance

 

 

 

 

has specially adapted phone and dials

 

 

 

 

numbers and answers calls without

 

 

 

 

assistance

 

 

 

 

chooses or needs ALR staff to help them

 

 

 

 

make calls or make the calls on their behalf

 

 

 

 

 

 

 

 

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