Individual service plans: Assisted living’s key to quality care

Roger, a resident in your assisted living community, has diabetes. His ability to walk independently is deteriorating, and he has fallen several times. He suffers from periodic depression. Despite his problems, he values his independence and wants to be as self-sufficient as possible. Attending church regularly and staying in touch with old friends are important to him.

How will your assisted living (AL) community care for Roger? How will you make sure that caregivers know and understand his needs, preferences and goals? How will you make sure he receives appropriate, consistent care?

The individual service plan (ISP) is the key document for assuring that Roger gets the care he needs.

The ISP (also known as a “care plan,” “plan of care,” “service program,” etc.) is a written or electronic document that describes resident care in each important life domain. A good ISP addresses the resident’s health status, including physical health, vision and hearing, and mental health. It addresses cognition and behaviors. The ISP also includes activities of daily living (ADLs) such as eating, bathing, toileting, dressing, mobility and transferring, along with areas of risk, such as falls. Finally, the ISP addresses the resident’s personal interests, desired activities and desired community involvement. If the resident is employed or would like to be employed, vocational goals also are included.

A good ISP brings all elements of a resident’s care together so that anyone reading it can immediately see the care the resident receives, who is responsible for providing the care and how and when it will be delivered. It helps ensure that residents receive the right care at the right time and that their personal strengths and dignity are respected.

Unfortunately, many AL providers view the ISP as just another “paperwork” requirement and do not take it seriously. Without good ISPs, however, you are at risk of providing inadequate or inconsistent care to your residents.


Start with a good assessment. Because the ISP is based on the resident assessment, begin by making sure it is complete and comprehensive. The assessment must identify all of the resident’s strengths, needs, goals and risks for each of the life domains—including health status, cognition and behaviors, ADLs, personal interests, activities and community involvement.

Make sure that you conduct the assessment before admitting a resident to your facility. That way, you will only admit people you are able to care for. Ask lots of questions so that you get a complete understanding of the resident’s needs. In addition to involving the resident and/or legal representative in the assessment, consider involving others who know the resident well, including case workers, family members, good friends, medical professionals and former caregivers.

Link the assessment to the ISP. For each resident need or risk identified in the assessment, the ISP describes what will be done, how it will be done, when it will be done and who will do it. It describes how resident strengths and preferences will be considered, and it sets a measurable goal for each resident need or risk.

For example, if the assessment identifies a risk of falls, the ISP describes in detail how the AL provider will help reduce that risk. It establishes a measurable goal (for example, “no more falls while moving from bed to a chair”). If the assessment discovers that the resident wants to keep attending church, then the ISP describes how the AL community will support the resident’s ability to attend, setting a measurable goal (for example, attending church at least twice a month). Similarly, the ISP should specify how treatment will be provided for any medical condition, how behaviors will be addressed and how the needed ADL support will be provided.

Every resident is different, and his or her ISP should be tailored to meet individual needs, strengths and goals. First and foremost, involve the resident (and/or the resident’s legal representative). Others to include are the resident’s family, good friends, and the caseworker or medical professionals.


Caregivers often do not know that an ISP exists or they are not encouraged to review it. A good ISP, however, contains important information that caregivers should know. They should have access to the ISP for each resident they care for, and they should be encouraged to check it if they have a question about the resident’s care. Caregivers also should be notified when an ISP changes. A best practice is to have a “sign-off” where caregivers indicate that they have reviewed and understand each ISP change.

Routinely review the ISP and update it if necessary. The ISP should be reviewed at least every six months for residents whose conditions are stable, and more frequently for residents experiencing frequent changes. If something has changed, then update the ISP accordingly. Make sure you review and update the ISP anytime a resident experiences a change in needs, abilities or physical or mental condition. Involve key people in revising the ISP, just as when the original ISP was created. Caregivers can be especially helpful in revising ISPs, because they know the resident well and may have good suggestions.

Back to the example of Roger. Roger is dealing with diabetes, depression and falls, and he is having increasing difficulty carrying out ADLs. At the same time, he is seeking to maintain his independence, friendships and spiritual life. Roger’s ISP addresses his needs, strengths, preferences and goals in each of these areas.

Diabetes—What medications does he receive, and who administers them? What kind of monitoring takes place? Who is responsible for monitoring? What dietary restrictions are in place? What other interventions are in place to control Roger’s diabetes? What are Roger’s goals with respect to his diabetes (for example, keeping his blood glucose level within a certain range)?

Depression—What are the signs or behaviors that indicate he is depressed? What generally triggers depressive episodes? What medications does he receive, and who administers them? What monitoring takes place? Who is responsible for monitoring? What staff interventions are in place to prevent depression or to deal with depression when it occurs? What are Roger’s goals with respect to his depression (for example, keeping his involvement with his church and his friends)?

Falls—What is his current mobility status? What adaptive devices does he use? What has been the cause of falls in the past? What interventions are in place to promote safety? What are Roger’s goals with respect to falls and mobility (for example, to be able to safely walk throughout the residence)?

ADLs—What are his abilities for self-care? What staff interventions will help him maintain or improve his level of function? What are Roger’s goals with respect to ADLs (for example, to maintain the ability to dress, eat and toilet with minimal assistance)?

Social contacts—Who are the social contacts that he values? How often and where does he want to interact with them? What does staff need to do to maintain his desired contacts and activities? What are Roger’s goals with respect to social contacts (for example, going to church twice monthly and playing cards every week)?

When caregivers understand this ISP and actively carry it out, Roger will be receiving excellent care that meets his needs, goals and preferences.

Gail Nordheim, MA, has worked with AL and government long-term care (LTC) programs since 1999. She consults with AL facilities on regulatory compliance, quality improvement and process improvement. She coordinated development of the nine-volume Wisconsin Assisted Living Association (WALA) Assisted Living Standards of Practice. She authored several quality compliance worksheets that help Wisconsin AL facilities understand state regulations.

Susan Schneider, BSN, RN, has more than 30 years of experience in senior and LTC. She consults on quality and process improvement and plans of correction and provides training for AL managers and staff. She helped develop the WALA Assisted Living Standards of Practice. In skilled nursing, she has served as staff development coordinator, admissions nurse, assistant director of nursing and director of nursing.

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