Sabrina Sellers, RN DSN, with over 24 years of experience in residential care, home health, and ICU, led this training and walked us through the process of implementing (Individualized Service Plan) ISPs in accordance with Arizona Department of Health Services regulations (AAC R9-10-808).

What Is an ISP and Why Does It Matter?

By law, every new resident in Arizona must have an ISP completed within 14 days of admission. This written plan outlines the resident’s needs—whether supervisory, personal, directed, or behavioral health care—and must be updated regularly.

Frequency depends on the level of care:

• Supervisory care – reviewed annually.
• Personal care – reviewed every six months.
• Directed care (including residents with dementia) – reviewed every three months, or sooner if there is a significant change.

Each ISP must be signed by the resident (if possible), their representative, the facility manager, and the reviewing physician or behavioral health provider.

A Holistic, Person-Centered Assessment

An effective ISP goes beyond physical needs. It captures information across five domains:

During training, Sellers shared the case of Mr. James H., an 84-year-old former firefighter with Alzheimer’s. His initial profile noted his career, but more details were needed:

• Does he respond with agitation to loud noises (sirens, alarms) due to his background?
• What are his eating habits and food preferences?
• Does his spiritual identity play a role in comfort at end of life?

By asking open-ended questions of his family and observing his daily responses, the team could build an ISP that respects who James was and who he is now, while creating realistic, measurable goals to guide care.

Staff Training and Daily Documentation

Even the best ISP is only as strong as the team implementing it. Sellers underscored two essentials:

1. Daily documentation – Staff should record interactions, observations, refusals, and changes in condition. This running log becomes critical for quarterly reviews and timely updates.
2. Consistent training – All staff must understand how to apply the ISP in real time, so residents receive the same standard of care regardless of who is on shift.

She also highlighted that ISPs must align with facility policies and procedures, and that communication across departments—nursing, activities, dining, and family engagement—is vital.

Key Takeaways for Memory Care Teams

• Complete ISPs within 14 days of admission.
• Review quarterly for directed care and update whenever a significant change occurs.
• Include all five domains: cognitive, emotional, physical, social, and spiritual.
• Involve residents, families, and staff in the process.
• Document daily to support accurate reviews.