Veritas Resident Service Plan Form (RSP)

Page 1 of 8 RSP Form Revised 011420

Community: ____________________________________ Apt#: ____________ Resident Name: ___________________________________________ Code Status: _________ Primary Contact/Responsible Party: ___________________________________________________ Telephone: _________________ Primary Physician(s): _______________________________________________________________ Telephone: _________________ 1. MONITORING AND ASSESSMENT — MEDICAL CONDITIONS (INCLUDING RESPIRATORY)

Date Description of Needs Services to be Provided When How Often By Whom

2. MONITORING AND ASSESSMENT — COGNITIVE IMPAIRMENTS, COMMUNICATION IMPAIRMENTS, PSYCHIATRIC ILLNESSES AND BEHAVIORS

Date Description of Needs Services to be Provided When How Often By Whom

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Veritas Resident Service Plan Form (RSP)

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3. CARE AND SERVICE — RISK FACTOR MANAGEMENT (EXAMPLE: FALLS, SKIN BREAKDOWN, WEIGHT LOSS, DEHYDRATION, COMBATIVENESS, WANDERING)

Date Description of Needs Services to be Provided When How Often By Whom

4. CARE AND SERVICE — MEDICATION MANAGEMENT (INCLUDING MEDICATED DROPS AND SPRAYS)

Date Description of Needs Services to be Provided When How Often By Whom

Resident self-administers medication independently

Evaluate the resident’s ability to safely self-administer medications.

Authorized Nursing Staff

Resident is unable to self-administer medication

1) Medication administration program. Medications will be administered as prescribed.

As scheduled on the MAR

Authorized Nursing Staff

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Veritas Resident Service Plan Form (RSP)

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5. CARE AND SERVICE — ASSISTANCE WITH ADLS (BATHING, TOILETING, MOBILITY, TRANSFERS, ORAL CARE AND GROOMING, DRESSING, FEEDING) Date ADL Needs I S

B 1 P

2 P

Services to be Provided When How Often By Whom

Eating Assistance Type: ______________ � Special diet: ______ � Cut up food � Mechanical soft � Pureed � Escort to meals

Mobility Assistance � Cane � Walker � W/C � Escort to activities � Stairs � Bed

Transfer Assistance

Toileting Assistance

� Incontinence bladder

� Incontinence bowel

� Toileting schedule

Bathing Assistance Showering: � Yes � No

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Veritas Resident Service Plan Form (RSP)

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5. CARE AND SERVICE (CONTINUED) – ASSISTANCE WITH ADLS (BATHING, TOILETING, MOBILITY, TRANSFERS, ORAL CARE AND GROOMING, DRESSING, FEEDING) Date ADL Needs I

1 P

2 P

Services to be Provided When How Often By Whom

Tub Bath: � Yes � No

Oral Care & Grooming � Dentures � Upper � Lower � Partial

Dressing Assistance

Date ADL Needs I

1 P

Services to be Provided When How Often By Whom

Meal Preparation Housekeeping Shopping Managing Finances Transportation Telephone Use 6. CARE AND SERVICE — PERFORMING TREATMENTS FOR PHYSICAL /MEDICAL CONDITIONS

Date Description of Needs Services to be Provided When How Often By Whom

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S B

S B

Veritas Resident Service Plan Form (RSP)

Page 5 of 8 RSP Form Revised 011420

7. CARE AND SERVICE — MANAGEMENT OF PROBLEMATIC BEHAVIOR

Date Description of Needs Services to be Provided When How Often By Whom

8. OTHER SERVICES

Date Description of Needs Services to be Provided When How Often By Whom

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Veritas Resident Service Plan Form (RSP)

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9. PASTORAL CARE – RELIGIOUS AFFILIATION, CLERGY, SUPPORT GROUPS, OTHER SERVICES

Date Description of Needs Services to be Provided When How Often By Whom

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Veritas Resident Service Plan Form (RSP)

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10. ACTIVITIES SERVICES Date Description of Needs Services to be Provided When How Often By Whom

Activity Pursuits Initial Activity Assessment On admission

Activity Director

Opportunities for social interaction Daily/ Evenings

Activity Staff

Provide in-room activities supplies Daily/ Evenings

Activity Staff

Provide 1:1 visits As needed Activity Staff

Provide transportation for community reintegration As needed Transport. Coordinator

11. DIETARY SERVICES

Date Description of Needs Services to be Provided When How Often By Whom

Diet and between meal snacks per physician order

Diabetic Program

Hydration Program

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Veritas Resident Service Plan Form (RSP)

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12. NUTRITION SERVICES Date Description of Needs Services to be Provided When How Often By Whom

Review of Nutritional Assessment information Weights per Physician Order

On Admission

Dietician

_______________________________________ ______________________________________

Date

_______________________________________ ______________________________________ Executive Director (ED) or Designee

Date

Service Plan Review/Revision

________________________________ ________________________________ _________________ Name

Signature

Date

________________________________ ________________________________ _________________ Name

Signature

Date

________________________________ ________________________________ _________________ Name

Signature

Date

________________________________ ________________________________ _________________ Name

Signature

Date

1st 2nd 3rd_______________________________________ ______________________________________ Resident Care Director (RCD) or Designee Date Resident / Responsible Party