§ 2800.227. Development of the final support plan.

 (a)  Each resident requiring services shall have a written final support plan developed and implemented within 30 days after admission to the residence. The final support plan shall be documented on the Department’s support plan form.

 (b)  A residence may use its own support plan form if it includes the same information as the Department’s support plan form. An LPN, under the supervision of an RN, shall review and approve the final support plan.

 (c)  The final support plan shall be revised within 30 days upon completion of the annual assessment or upon changes in the resident’s needs as indicated on the current assessment. The residence shall review each resident’s final support plan on a quarterly basis and modify as necessary to meet the resident’s needs.

 (d)  Each residence shall document in the resident’s final support plan the dietary, medical, dental, vision, hearing, mental health or other behavioral care services that will be made available to the resident, or referrals for the resident to outside services if the resident’s physician, physician’s assistant or certified registered nurse practitioner, determine the necessity of these services. This requirement does not require a residence to pay for the cost of these medical and behavioral care services. The final support plan must document the assisted living services and supplemental health care services, if applicable, that will be provided to the resident.

 (e)  The resident’s final support plan must document the ability of the resident to self-administer medications or the need for medication reminders or medication administration and the ability of the resident to safely operate key-locking devices. Strategies that promote interactive communication on the part of and between direct care staff and individual residents shall also be included in the final support plan.

 (f)  A resident shall be encouraged to participate in the development and implementation of the final support plan. A resident may include a designated person or family member in making decisions about services.

 (g)  Individuals who participate in the development of the final support plan shall sign and date the support plan.

 (h)  If a resident or designated person is unable or chooses not to sign the final support plan, a notation of inability or refusal to sign shall be documented.

 (i)  The final support plan shall be accessible by direct care staff persons at all times.

 (j)  A resident or a designated person has a right to request the review and modification of his support plan.

 (k)  The residence shall give a copy of the final support plan to the resident and the resident’s designated person. The final support plan shall be attached to or incorporated into and serve as part of the resident-residence contract.

Cross References

   This section cited in 55 Pa. Code §  2800.22 (relating to application and admission); 55 Pa. Code §  2800.54 (relating to qualifications for direct care staff persons); 55 Pa. Code §  2800.181 (relating to self-administration); and 55 Pa. Code Appendix A (relating to assisted living resident rights: during residency and during discharge or termination of residency).

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