Section 146.245  Assessment and Service Plan and Quarterly Evaluation

a)         Interview:  The SLP provider shall conduct a standardized interview geared toward the resident's service needs at or before the time of occupancy but not before the DON, or successor tool, and other required PAS assessments are completed and determinations provided to the SLP provider.

b)         Initial Assessment:  The SLP provider shall complete an initial assessment and service plan within 24 hours after admission that identifies needs and potential immediate problems.  Each assessment shall be completed by, or co-signed by, a licensed practical nurse or a registered professional nurse.

c)         Comprehensive Resident Assessment:  The SLP provider shall complete a Comprehensive Resident Assessment Instrument (RAI) within 14 days after admission, annually and upon a significant change in the resident's mental or physical status.  Each RAI shall be completed by, or co-signed by, a registered professional nurse.

d)         Service Plan:  Within seven days after completion of the RAI, a written service plan shall be developed by, or co-signed by, a registered professional nurse, with input from the resident and his or her designated representative. This includes coordination and inclusion of services being delivered to a resident by an outside entity. The service plan shall include a description of expected outcomes, approaches, frequency and duration of services provided and whether the services will be provided by licensed or unlicensed staff.  The service plan must be individualized to address the health and behavior needs of each resident.  The service plan shall document any services recommended by the SLP provider that are refused by the resident.  The service plan shall be reviewed and updated in conjunction with the quarterly evaluation or as dictated by changes in resident needs or preferences.

e)         Quarterly Evaluation: A quarterly evaluation of the health and behavior status of each resident using a Department designated form shall be completed by, or co-signed by, a registered professional nurse.

f)         Service Plan for Identified Sex Offenders:  Within seven days after completion of the RAI, a written service plan shall be developed by, or co-signed by, a registered professional nurse that addresses the following:

1)         the amount of supervision required by the individual to ensure the safety of all residents, staff and visitors; and

2)         determination of approaches developed in the service plan are appropriate and effective in dealing with any behaviors specific to the identified offender.

g)         Progress Notes:  Progress notes shall be completed at least monthly to document decline or improvement in resident status.  A progress note does not have to be completed if there is no change in resident status.  Any SLP staff may write progress notes.

h)         The SLP manager or licensed nursing staff shall alert the resident, his or her physician and his or her designated representative when a change in a resident's mental or physical status is observed by staff.  Except in life-threatening situations, the reporting shall be within 24 hours after the observation.  Serious or life-threatening situations should be reported to the physician and the resident's designated representative immediately.  The SLP staff shall be responsible for reporting only those changes that should be apparent to observers familiar with the conditions of older persons or persons with disabilities.

(Source:  Amended at 44 Ill. Reg. 2331, effective January 15, 2020)