Planning and Support Agreements

The Community Care and Assisted Living Act and the Assisted Living Regulation set out operators’ responsibilities to promote and protect residents’ health and safety in assisted living residences.

Operators have important responsibilities:

• In screening for admission
• When a resident moves in
• During their stay, and
• At the end of their stay

Good planning and detailed agreements with residents are important to creating accountability and transparency. They help set up a good relationship between the operator and the resident from the start and outline what services a resident needs and by whom and how they will be delivered.

Screening for Admission

Before accepting someone as a resident, operators need to make sure the person meets the criteria for assisted living:

• Can live here safely, given their needs and capabilities
• Is able to make decisions on their own, or lives with a spouse who can do so on their behalf
• Is able to take steps to protect themselves or follow directions in an emergency
• Does not have behaviours that jeopardize the health and safety of others
• Does not require unscheduled professional health services on a regular basis
• Does not require care (i.e.,dependent on caregivers for continuing assistance or direction, as defined in the Community Care and Assisted Living Act)

Information to Potential Residents

Operators must provide potential residents with the information they need to make an informed decision about the residence. This includes copies of key policies, the rules of the residence, costs, fees and optional services.

• See About Assisted Living, Costs for more information on costs and fees.

Agreements Needed When a Resident Moves In

When a new resident moves in, the operator needs to develop three agreements with them:

• The Residency Agreement
• The Short-term Service Plan; and
• The Personal Service Plan

These agreements set out all of the expectations and services that promote and protect a resident’s health and safety and that meet their individual needs, capabilities and preferences.The agreements must be reviewed and adjusted throughout a resident’s stay.

These agreements, developed ‘up front’ with a new resident, are also helpful if and when the times comes for the resident to move out of assisted living.

Residency Agreement

The agreement must include:

• Contact information (who the contract is between)
• The term of the residency;
• Responsibilities of the operator including what the resident will receive as hospitality services and assisted living services;
• The general level and type of training and experience of staff who provide assisted living services;
• The rules of the residence;
• Any electronic surveillance used at the residence;
• Rights and responsibilities of residents; and
• Costs and fees; and
• What parameters will guide a decision to end a residency

See Schedule C of the Assisted Living Regulation for detailed information about the residency agreement.

Short-term Service Plan

The short-term service plan can be a very simple and is developed as soon as a new resident moves in. Its purpose is to:

• Give staff enough information about the services the resident needs to support their health and well-being in the short term; and
• Give the operator and staff some time to get to know the resident, their needs and capabilities while a more detailed personal service plan is being developed

Personal Service Plan

The personal service plan is one of the most important plans for a resident. The intent of the personal service plan is to describe in more detail the nature and scope of services a resident will receive, taking into account their needs, capabilities and preferences. It includes:

• A description of all services the resident receives, as agreed to in the residency agreement
• An explanation of how services are tailored to meet the resident’s needs, capabilities, culture and preferences
• A list of medications and a description of the supports the resident needs, if the resident is receiving assistance with managing their medication
• Any medically-related information that is needed to ensure appropriate services are in place
  i.e., a resident request for ‘no CPR’ is on file and communicated to all staff

And, if required:

• Any diet adjustments needed because of nutritional needs, allergies, intolerances, or religious, cultural or personal preferences
• An individual dietary plan if the resident needs to follow a therapeutic diet; and
• A behaviour management plan

The plan must be developed:

• Within 30 days in the seniors and persons with disabilities and mental health classes    
• Within 7 days of the resident moving in the supportive recovery class

The plan must be reviewed:

• Annually in the seniors and persons with disabilities and mental health classes  
• Monthly in the supportive recovery class

End of Residency

Operators have important responsibilities in:

• Monitoring residents’ health and safety
• Being responsive to their changing needs
• Determining if and when a resident can no longer live safely in the residence; and
• Ensuring a smooth transition to another living arrangement, if needed

Operators are responsible for:

• Creating a policy that describes the process to determine if a resident needs to move out of assisted living and the process to end the residency. (The policy can be part of residency agreement)
• Ensuring any needed assessments are done by an appropriate health professional
• Establishing early on who needs to be on the transition team and working with the team to update the personal services plan and develop a transition plan

If an operator has concerns about a resident’s decline in health or capabilities, this is the time to engage the resident and others in discussions about:

• Increasing services; or
• Transitioning out of assisted living

A resident may need an increase in services but be able to stay in the residence if the underlying condition is manageable, treatable or of short duration.

A resident may need to transition to out of assisted living when:

• Their personal service needs that can no longer be met in the residence

The resident:

• Can no longer make safe decisions on their own behalf and doesn’t have a spouse living with them who can do so
• Exhibits behaviours that jeopardize their own or others’ safety and well-being
• Requires 24-hour supervision or regularly requires unscheduled professional care; or
• Is not complying with the terms of the residency agreement

Transition Plan

Operators need to develop a transition plan for a resident:

• Whose needs can no longer be met in assisted living
• Who no longer needs assisted living services; or
• Who states their intention to move out

A transition plan pulls together all the important information to assist with a safe move. It describes the “what, when, who and how”, that is:

• What are the relocation plans for the resident
• When will the move happen
• Who is responsible for making those arrangements
• How will health and safety risks for the resident be minimized until their transfer is arranged

An assisted living residence is a home for each individual resident.  Change can be difficult so it’s important to be respectful, supportive and understanding in this process of change for the resident. Discuss the plan with the resident; involve others in answering the resident’s questions and help make the process as smooth as possible.