481—57.22 (135C) Service plan.
	 57.22(1) Prior to admission of a resident, the administrator or the administrator’s designee shall develop a written and organized orientation plan. The plan shall be designed to assist the resident in adapting to the facility and to assist the facility staff in becoming knowledgeable of the resident and the resident’s needs. (III)
	 57.22(2) Within 30 days of admission, the administrator or the administrator’s designee shall, in conjunction with the resident, other facility staff or any organization that works with or serves the resident, develop a written, individualized, and integrated program of ongoing services for the resident. (III)
	  a.   	 The program shall be planned and implemented to address the resident’s priorities and assessed needs, such as living, rehabilitation, activity, behavioral, emotional, mental health and social, and shall take into consideration the resident’s personal goals and preferences, including the resident’s preferred living situation. (III)
	  b.   	 The service plan shall include specific goals and objectives with regular documentation of each. (III)
	  c.   	 The service plan shall be reviewed at least quarterly, or more often as necessary. (III)
	 57.22(3) Communications related to service plan changes or changes in the resident’s condition shall occur within five working days of the change, and shall be conveyed to all individuals inside and outside the residential care facility who work with the resident, as well as to the resident’s family members or responsible party. (III)