Individual Service Plans

By Pat Hoogevoorst, RN, Clinical Services Director at Valley VNA Senior Care

All residents who move into Valley VNA Senior Care Assisted Living have a comprehensive assessment prior their move date.  These assessments are conducted by one of the registered nurses from the Valley VNA clinical team.  The purpose of the assessment is to establish the needs and abilities of the person so an Individual Service Plan (ISP) can be developed. The ISP is the guide the staff will use to provide appropriate care for our new resident.

The assessment will cover many areas including physical health, medications, presence of pain and intensity, the need for nursing procedures, and mental and emotional health. We look at behavioral patterns, a person’s capacity for self-care and personal care such as dressing and toileting, and risk factors for falls, choking or elopement (wandering off). Social needs, decision-making, nutritional needs, and preferences for certain daily routines are all recorded. We also consider outside services that may be required to properly address all of the person’s needs.

The assessments are completed in person with the resident and his or her family member or Power of Attorney for Health Care (POA).  Some information is gathered from past health histories or recent doctors’ visits, medication lists, discharge summaries, family caregivers, or third party providers like home care or hospice caregivers. Other portions of the assessment are completed during the meeting.

The ISP clearly details care needs in all areas, when they are to be completed, who is responsible for the care, and the desired goal for the resident.  The assessments also help the Valley VNA team recommend the most appropriate court, or section of our residence, where the person can be happiest, most comfortable, and safe.

ISPs are fluid documents; as a resident’s needs change, so does the ISP.  Assessments are reviewed at least 30 days after move-in, after any significant changes in a resident’s status, and every year.  We include the resident and his or her family member or POA whenever we update the ISP because it is an excellent opportunity to keep the lines of communication open between all parties. Our goal is to create an in-depth person-centered ISP that helps each resident age with grace and dignity.